- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.42 / $52.42 / $52.42
| Facility | 26 | $52.42 | $52.42 | $52.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.15 / $124.50 / $236.82
| Professional | | $99.15 | $124.50 | $236.82 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $42.90 / $42.90 / $42.90
| Facility | 26 | $42.90 | $42.90 | $42.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.22 / $350.13 / $424.66
| Professional | | $210.22 | $350.13 | $424.66 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $114.80 / $179.17 / $431.01
| Facility | 26 | $114.80 | $179.17 | $431.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.09 / $230.10 / $464.50
| Professional | | $171.09 | $230.10 | $464.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $99.48 / $163.50 / $339.38
| Facility | 26 | $99.48 | $163.50 | $339.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.18 / $214.45 / $365.75
| Professional | | $181.18 | $214.45 | $365.75 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $245.13 / $245.13 / $245.13
| Facility | 26 | $245.13 | $245.13 | $245.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.69 / $261.18 / $3,099.85
| Professional | | $145.69 | $261.18 | $3,099.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.44 / $250.00 / $448.89
| Professional | | $132.44 | $250.00 | $448.89 |