- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $75.86 / $75.86 / $75.86
| Facility | 26 | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $181.97 / $354.81
| Professional | | $128.82 | $181.97 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $77.62 / $177.83
| Professional | 26 | $57.54 | $77.62 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $691.83 / $691.83
| Professional | | $446.68 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $194.98 / $302.00 / $302.00
| Professional | 26 | $194.98 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $281.84 / $467.74
| Professional | | $154.88 | $281.84 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.86 / $128.82 / $218.78
| Professional | 26 | $75.86 | $128.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $316.23 / $575.44
| Professional | | $165.96 | $316.23 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.86 / $141.25 / $251.19
| Professional | 26 | $75.86 | $141.25 | $251.19 |