- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.97 / $87.97 / $87.97
| Facility | 26 | $87.97 | $87.97 | $87.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.86 / $441.92 / $441.92
| Professional | | $331.86 | $441.92 | $441.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $59.90 / $87.97 / $87.97
| Professional | 26 | $59.90 | $87.97 | $87.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.68 / $348.11 / $382.92
| Professional | | $243.68 | $348.11 | $382.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $47.07 / $67.23 / $73.95
| Professional | 26 | $47.07 | $67.23 | $73.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.18 / $513.66 / $1,975.16
| Professional | | $363.18 | $513.66 | $1,975.16 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.95 / $99.80 / $388.09
| Professional | 26 | $69.95 | $99.80 | $388.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.31 / $323.67 / $428.20
| Professional | | $208.31 | $323.67 | $428.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.85 / $67.23 / $94.14
| Professional | 26 | $50.85 | $67.23 | $94.14 |