- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $93.89 / $116.38 / $122.54
| Facility | 26 | $93.89 | $116.38 | $122.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $600.35 / $600.35
| Professional | | $250.00 | $600.35 | $600.35 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $62.50 / $121.84 / $121.84
| Professional | 26 | $62.50 | $121.84 | $121.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.85 / $597.52 / $663.91
| Professional | | $517.85 | $597.52 | $663.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $86.49 / $99.80 / $110.89
| Professional | 26 | $86.49 | $99.80 | $110.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.64 / $604.36 / $779.98
| Professional | | $386.64 | $604.36 | $779.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.01 / $104.33 / $137.41
| Professional | 26 | $80.01 | $104.33 | $137.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.03 / $474.69 / $766.05
| Professional | | $395.03 | $474.69 | $766.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $68.47 / $76.95 / $131.90
| Professional | 26 | $68.47 | $76.95 | $131.90 |