- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $412.56 / $412.56 / $412.56
| Facility | 26 | $412.56 | $412.56 | $412.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.22 / $88.31 / $117.03
| Professional | | $68.22 | $88.31 | $117.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $49.14 / $58.95 / $66.40
| Professional | 26 | $49.14 | $58.95 | $66.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.35 / $119.00 / $174.83
| Professional | | $97.35 | $119.00 | $174.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.66 / $83.80 / $126.46
| Professional | 26 | $58.66 | $83.80 | $126.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.73 / $171.37 / $389.90
| Professional | | $74.73 | $171.37 | $389.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $51.93 / $94.67 / $138.05
| Professional | 26 | $51.93 | $94.67 | $138.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.50 / $133.63 / $247.73
| Professional | | $83.50 | $133.63 | $247.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $59.46 / $86.10 / $123.63
| Professional | 26 | $59.46 | $86.10 | $123.63 |