- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $173.78 / $416.87
| Facility | 26 | $85.11 | $173.78 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $436.52 / $851.14
| Professional | | $323.59 | $436.52 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $87.10 / $87.10
| Facility | 26 | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $478.63 / $1,023.29
| Professional | | $331.13 | $478.63 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $18.62 / $100.00 / $245.47
| Facility | 26 | $18.62 | $100.00 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $588.84 / $1,096.48
| Professional | | $323.59 | $588.84 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $489.78 / $912.01
| Professional | | $331.13 | $489.78 | $912.01 |