- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $281.84 / $281.84 / $281.84
| Facility | 26 | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $177.83 / $363.08
| Professional | | $134.90 | $177.83 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.26 / $77.62 / $186.21
| Professional | 26 | $60.26 | $77.62 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $199.53 / $288.40
| Professional | | $177.83 | $199.53 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.86 / $83.18 / $125.89
| Professional | 26 | $75.86 | $83.18 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $302.00 / $489.78
| Professional | | $199.53 | $302.00 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $134.90 / $218.78
| Professional | 26 | $89.13 | $134.90 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $309.03 / $478.63
| Professional | | $208.93 | $309.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $134.90 / $204.17
| Professional | 26 | $89.13 | $134.90 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $234.42 / $457.09
| Professional | | $181.97 | $234.42 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $104.71 / $194.98
| Professional | 26 | $79.43 | $104.71 | $194.98 |