- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | 26 | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $251.19 / $346.74
| Professional | | $173.78 | $251.19 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.99 / $38.90 / $85.11
| Professional | 26 | $23.99 | $38.90 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $389.05 / $549.54
| Professional | | $263.03 | $389.05 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.31 / $53.70 / $77.62
| Professional | 26 | $36.31 | $53.70 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $616.60 / $870.96
| Professional | | $346.74 | $616.60 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $47.86 / $85.11 / $112.20
| Professional | 26 | $47.86 | $85.11 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $501.19 / $912.01
| Professional | | $295.12 | $501.19 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $40.74 / $69.18 / $112.20
| Professional | 26 | $40.74 | $69.18 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $380.19 / $1,023.29
| Professional | | $213.80 | $380.19 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $39.81 / $48.98 / $97.72
| Professional | 26 | $39.81 | $48.98 | $97.72 |