- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $97.56 / $112.01 / $176.41
| Facility | 26 | $97.56 | $112.01 | $176.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.56 / $500.19 / $1,715.25
| Professional | | $407.56 | $500.19 | $1,715.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.05 / $443.03 / $963.20
| Professional | | $354.05 | $443.03 | $963.20 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.95 / $87.95 / $87.95
| Facility | 26 | $87.95 | $87.95 | $87.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.54 / $549.41 / $964.61
| Professional | | $300.54 | $549.41 | $964.61 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $556.32 / $720.40 / $720.40
| Facility | 26 | $556.32 | $720.40 | $720.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.74 / $633.16 / $3,350.26
| Professional | | $386.74 | $633.16 | $3,350.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.41 / $554.76 / $1,196.96
| Professional | | $372.41 | $554.76 | $1,196.96 |