- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $99.66 / $99.66 / $99.66
| Facility | 26 | $99.66 | $99.66 | $99.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.91 / $460.90 / $1,518.64
| Professional | | $243.91 | $460.90 | $1,518.64 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.64 / $101.91 / $325.64
| Professional | 26 | $80.64 | $101.91 | $325.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.89 / $462.61 / $658.45
| Professional | | $287.89 | $462.61 | $658.45 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.88 / $104.93 / $183.96
| Professional | 26 | $75.88 | $104.93 | $183.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.09 / $147.66 / $258.77
| Professional | | $80.09 | $147.66 | $258.77 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $324.95 / $324.95 / $324.95
| Facility | 26 | $324.95 | $324.95 | $324.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.09 / $521.45 / $656.26
| Professional | | $453.09 | $521.45 | $656.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $124.43 / $145.19 / $192.60
| Professional | 26 | $124.43 | $145.19 | $192.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.45 / $370.53 / $665.28
| Professional | | $283.45 | $370.53 | $665.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.65 / $79.41 / $152.40
| Professional | 26 | $74.65 | $79.41 | $152.40 |