- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.92 / $60.92 / $60.92
| Facility | 26 | $60.92 | $60.92 | $60.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.34 / $209.97 / $315.01
| Professional | | $165.34 | $209.97 | $315.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $39.96 / $54.04 / $85.49
| Professional | 26 | $39.96 | $54.04 | $85.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.24 / $326.92 / $473.78
| Professional | | $223.24 | $326.92 | $473.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.12 / $84.32 / $121.32
| Professional | 26 | $60.12 | $84.32 | $121.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.77 / $247.44 / $465.63
| Professional | | $172.77 | $247.44 | $465.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $44.56 / $65.83 / $122.19
| Professional | 26 | $44.56 | $65.83 | $122.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.95 / $401.95 / $429.44
| Professional | | $401.95 | $401.95 | $429.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.45 / $351.98 / $477.99
| Professional | | $282.45 | $351.98 | $477.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.43 / $93.99 / $127.64
| Professional | 26 | $75.43 | $93.99 | $127.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $360.32 / $536.64
| Professional | | $198.37 | $360.32 | $536.64 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.50 / $96.36 / $151.30
| Professional | 26 | $50.50 | $96.36 | $151.30 |