- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $542.40 / $542.40 / $754.64
| Facility | 26 | $542.40 | $542.40 | $754.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.08 / $387.95 / $469.14
| Professional | | $258.08 | $387.95 | $469.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $66.54 / $82.76 / $128.65
| Professional | 26 | $66.54 | $82.76 | $128.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.22 / $388.96 / $733.73
| Professional | | $314.22 | $388.96 | $733.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $84.85 / $121.21 / $167.64
| Professional | 26 | $84.85 | $121.21 | $167.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.08 / $628.90 / $684.56
| Professional | | $297.08 | $628.90 | $684.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $78.39 / $162.58 / $181.50
| Professional | 26 | $78.39 | $162.58 | $181.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.30 / $443.62 / $707.06
| Professional | | $347.30 | $443.62 | $707.06 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $82.00 / $113.65 / $164.20
| Professional | 26 | $82.00 | $113.65 | $164.20 |