- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $194.98 / $194.98
| Facility | 26 | $100.00 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $295.12 / $512.86
| Professional | | $223.87 | $295.12 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $138.04 / $323.59
| Professional | 26 | $97.72 | $138.04 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $114.82 / $169.82
| Professional | 26 | $97.72 | $114.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $239.88 / $263.03
| Professional | | $165.96 | $239.88 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $77.62 / $109.65 / $120.23
| Professional | 26 | $77.62 | $109.65 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $354.81 / $707.95
| Professional | | $218.78 | $354.81 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $102.33 / $151.36 / $338.84
| Professional | 26 | $102.33 | $151.36 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $251.19 / $501.19
| Professional | | $190.55 | $251.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $112.20 / $190.55
| Professional | 26 | $85.11 | $112.20 | $190.55 |