- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | 26 | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $354.81 / $512.86
| Professional | | $288.40 | $354.81 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $66.07 / $114.82
| Professional | 26 | $54.95 | $66.07 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $15.85 / $74.13 / $104.71
| Facility | 26 | $15.85 | $74.13 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $1,000.00 / $1,548.82
| Professional | | $269.15 | $1,000.00 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.18 / $208.93 / $338.84
| Professional | 26 | $69.18 | $208.93 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.65 / $109.65 / $131.83
| Professional | 26 | $109.65 | $109.65 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $302.00 / $575.44
| Professional | | $208.93 | $302.00 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $46.77 / $61.66 / $114.82
| Professional | 26 | $46.77 | $61.66 | $114.82 |