- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $590.29 / $590.29 / $590.29
| Facility | 26 | $590.29 | $590.29 | $590.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.49 / $225.80 / $250.32
| Professional | | $131.49 | $225.80 | $250.32 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $64.68 / $77.76 / $87.50
| Professional | 26 | $64.68 | $77.76 | $87.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.71 / $193.71 / $364.44
| Professional | | $174.71 | $193.71 | $364.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.54 / $113.63 / $163.85
| Professional | 26 | $79.54 | $113.63 | $163.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.16 / $292.30 / $435.57
| Professional | | $139.16 | $292.30 | $435.57 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $78.33 / $138.25 / $197.51
| Professional | 26 | $78.33 | $138.25 | $197.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.59 / $260.70 / $625.58
| Professional | | $173.59 | $260.70 | $625.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $82.91 / $114.42 / $195.08
| Professional | 26 | $82.91 | $114.42 | $195.08 |