- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $474.61 / $474.61 / $474.61
| Facility | 26 | $474.61 | $474.61 | $474.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.03 / $171.35 / $178.06
| Professional | | $130.03 | $171.35 | $178.06 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.40 / $71.78 / $75.95
| Professional | 26 | $57.40 | $71.78 | $75.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.90 / $218.71 / $340.00
| Professional | | $185.90 | $218.71 | $340.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $65.87 / $94.10 / $146.77
| Professional | 26 | $65.87 | $94.10 | $146.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.68 / $245.10 / $358.34
| Professional | | $162.68 | $245.10 | $358.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $73.62 / $110.63 / $158.81
| Professional | 26 | $73.62 | $110.63 | $158.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.15 / $189.98 / $324.20
| Professional | | $152.15 | $189.98 | $324.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $68.75 / $96.47 / $144.44
| Professional | 26 | $68.75 | $96.47 | $144.44 |