- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $81.28 / $81.28
| Facility | 26 | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $436.52 / $724.44
| Professional | | $251.19 | $436.52 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $74.13 / $74.13
| Facility | 26 | $63.10 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $954.99 / $1,412.54
| Professional | | $575.44 | $954.99 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $109.65 / $295.12 / $724.44
| Facility | 26 | $109.65 | $295.12 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,096.48 / $1,737.80
| Professional | | $588.84 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $234.42 / $295.12 / $575.44
| Facility | 26 | $234.42 | $295.12 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,000.00 / $1,584.89
| Professional | | $676.08 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $691.83 / $3,162.28
| Professional | | $316.23 | $691.83 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $691.83 / $1,318.26
| Professional | | $331.13 | $691.83 | $1,318.26 |