- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $94.40 / $94.40 / $94.40
| Facility | 26 | $94.40 | $94.40 | $94.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.65 / $225.80 / $275.14
| Professional | | $136.65 | $225.80 | $275.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.65 / $89.42 / $140.59
| Professional | 26 | $74.65 | $89.42 | $140.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.93 / $231.63 / $366.10
| Professional | | $169.93 | $231.63 | $366.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.62 / $130.02 / $187.07
| Professional | 26 | $97.62 | $130.02 | $187.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.66 / $241.72 / $625.79
| Professional | | $145.66 | $241.72 | $625.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.99 / $118.42 / $198.00
| Professional | 26 | $81.99 | $118.42 | $198.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.39 / $286.39 / $295.85
| Professional | | $286.39 | $286.39 | $295.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.25 / $250.79 / $340.58
| Professional | | $201.25 | $250.79 | $340.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $116.87 / $145.63 / $197.78
| Professional | 26 | $116.87 | $145.63 | $197.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.95 / $304.86 / $560.79
| Professional | | $190.95 | $304.86 | $560.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.07 / $158.13 / $249.93
| Professional | 26 | $89.07 | $158.13 | $249.93 |