- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $114.47 / $119.05 / $662.49
| Facility | 26 | $114.47 | $119.05 | $662.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.00 / $312.08 / $377.45
| Professional | | $171.00 | $312.08 | $377.45 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $181.40 / $181.40 / $181.40
| Facility | 26 | $181.40 | $181.40 | $181.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.97 / $468.68 / $822.85
| Professional | | $382.97 | $468.68 | $822.85 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $864.48 / $1,108.64 / $1,108.64
| Facility | 26 | $864.48 | $1,108.64 | $1,108.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.10 / $545.30 / $2,146.96
| Professional | | $408.10 | $545.30 | $2,146.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.10 / $528.95 / $802.86
| Professional | | $408.10 | $528.95 | $802.86 |