- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $103.60 / $127.89 / $198.69
| Facility | 26 | $103.60 | $127.89 | $198.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.70 / $425.00 / $638.00
| Professional | | $282.70 | $425.00 | $638.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.08 / $127.50 / $198.43
| Professional | 26 | $85.08 | $127.50 | $198.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $94.73 / $94.73 / $94.73
| Facility | 26 | $94.73 | $94.73 | $94.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.45 / $392.39 / $821.50
| Professional | | $288.45 | $392.39 | $821.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $82.31 / $114.98 / $194.46
| Professional | 26 | $82.31 | $114.98 | $194.46 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $96.46 / $96.46 / $96.46
| Facility | 26 | $96.46 | $96.46 | $96.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.93 / $554.30 / $931.00
| Professional | | $278.93 | $554.30 | $931.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.93 / $122.71 / $206.72
| Professional | 26 | $75.93 | $122.71 | $206.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.39 / $463.35 / $817.06
| Professional | | $280.39 | $463.35 | $817.06 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $78.79 / $103.59 / $187.37
| Professional | 26 | $78.79 | $103.59 | $187.37 |