- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $169.82 / $416.87
| Facility | 26 | $85.11 | $169.82 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $426.58 / $831.76
| Professional | | $257.04 | $426.58 | $831.76 |
- 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
- $281.84 / $446.68 / $977.24
| Professional | | $281.84 | $446.68 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $18.62 / $100.00 / $239.88
| Facility | 26 | $18.62 | $100.00 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $537.03 / $1,000.00
| Professional | | $269.15 | $537.03 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $446.68 / $812.83
| Professional | | $263.03 | $446.68 | $812.83 |