- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $79.19 / $79.19 / $130.77
| Facility | 26 | $79.19 | $79.19 | $130.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.55 / $177.89 / $254.65
| Professional | | $155.55 | $177.89 | $254.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.59 / $77.90 / $101.65
| Professional | 26 | $67.59 | $77.90 | $101.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.55 / $425.19 / $445.13
| Professional | | $344.55 | $425.19 | $445.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $149.26 / $184.19 / $192.53
| Professional | 26 | $149.26 | $184.19 | $192.53 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $86.87 / $86.87 / $86.87
| Facility | 26 | $86.87 | $86.87 | $86.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.34 / $291.00 / $458.97
| Professional | | $177.34 | $291.00 | $458.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $84.79 / $143.37 / $197.33
| Professional | 26 | $84.79 | $143.37 | $197.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.00 / $322.20 / $1,115.94
| Professional | | $179.00 | $322.20 | $1,115.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.12 / $144.22 / $476.34
| Professional | 26 | $80.12 | $144.22 | $476.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.00 / $314.36 / $404.62
| Professional | | $179.00 | $314.36 | $404.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $78.38 / $133.79 / $186.66
| Professional | 26 | $78.38 | $133.79 | $186.66 |