- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $134.86 / $134.86 / $134.86
| Facility | 26 | $134.86 | $134.86 | $134.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.83 / $455.13 / $1,761.20
| Professional | | $275.83 | $455.13 | $1,761.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.54 / $571.39 / $1,050.24
| Professional | | $451.54 | $571.39 | $1,050.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.98 / $150.89 / $291.11
| Professional | | $106.98 | $150.89 | $291.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $324.95 / $324.95 / $324.95
| Facility | 26 | $324.95 | $324.95 | $324.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.86 / $836.12 / $1,090.30
| Professional | | $711.86 | $836.12 | $1,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.08 / $513.74 / $927.03
| Professional | | $453.08 | $513.74 | $927.03 |