- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.48 / $120.48 / $185.99
| Facility | 26 | $120.48 | $120.48 | $185.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $312.08 / $371.76
| Professional | | $275.00 | $312.08 | $371.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.61 / $551.01 / $760.39
| Professional | | $360.61 | $551.01 | $760.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.63 / $1,258.63 / $1,258.63
| Professional | | $1,258.63 | $1,258.63 | $1,258.63 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $135.43 / $135.43 / $135.43
| Facility | 26 | $135.43 | $135.43 | $135.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.85 / $555.62 / $1,004.76
| Professional | | $421.85 | $555.62 | $1,004.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.97 / $577.38 / $981.56
| Professional | | $435.97 | $577.38 | $981.56 |