- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $68.36 / $68.36 / $68.36
| Facility | 26 | $68.36 | $68.36 | $68.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.24 / $123.93 / $317.73
| Professional | | $88.24 | $123.93 | $317.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.26 / $68.36 / $101.60
| Professional | 26 | $50.26 | $68.36 | $101.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.91 / $255.27 / $280.81
| Professional | | $209.91 | $255.27 | $280.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $122.76 / $149.30 / $163.86
| Professional | 26 | $122.76 | $149.30 | $163.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $234.89 / $366.21
| Professional | | $136.66 | $234.89 | $366.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $76.93 / $137.80 / $212.42
| Professional | 26 | $76.93 | $137.80 | $212.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.90 / $237.10 / $728.40
| Professional | | $138.90 | $237.10 | $728.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.73 / $129.07 / $414.32
| Professional | 26 | $74.73 | $129.07 | $414.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.47 / $227.29 / $293.60
| Professional | | $136.47 | $227.29 | $293.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.73 / $123.84 / $161.78
| Professional | 26 | $74.73 | $123.84 | $161.78 |