- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $187.97 / $187.97 / $187.97
| Facility | 26 | $187.97 | $187.97 | $187.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $201.83
| Professional | | $176.45 | $176.45 | $201.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.38 / $30.04 / $30.04
| Professional | 26 | $28.38 | $30.04 | $30.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.43 / $244.43 / $337.73
| Professional | | $244.43 | $244.43 | $337.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $24.16 / $34.52 / $56.44
| Professional | 26 | $24.16 | $34.52 | $56.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.61 / $375.39 / $476.50
| Professional | | $254.61 | $375.39 | $476.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $35.97 / $58.91 / $62.90
| Professional | 26 | $35.97 | $58.91 | $62.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.07 / $173.36 / $336.82
| Professional | | $124.07 | $173.36 | $336.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.88 / $35.11 / $52.31
| Professional | 26 | $22.88 | $35.11 | $52.31 |