- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $593.05 / $593.05 / $593.05
| Facility | 26 | $593.05 | $593.05 | $593.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.32 / $209.52 / $251.29
| Professional | | $117.32 | $209.52 | $251.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $41.19 / $52.43 / $91.44
| Professional | 26 | $41.19 | $52.43 | $91.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.59 / $212.55 / $361.03
| Professional | | $187.59 | $212.55 | $361.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.67 / $106.11 / $115.24
| Professional | 26 | $80.67 | $106.11 | $115.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.66 / $268.02 / $478.91
| Professional | | $150.66 | $268.02 | $478.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $65.89 / $136.94 / $198.44
| Professional | 26 | $65.89 | $136.94 | $198.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.67 / $259.57 / $568.76
| Professional | | $187.67 | $259.57 | $568.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $51.60 / $112.26 / $165.02
| Professional | 26 | $51.60 | $112.26 | $165.02 |