- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | 26 | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $588.84 / $1,548.82
| Professional | | $371.54 | $588.84 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.13 / $112.20 / $234.42
| Professional | 26 | $74.13 | $112.20 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $562.34 / $707.95
| Professional | | $398.11 | $562.34 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $64.57 / $75.86 / $114.82
| Professional | 26 | $64.57 | $75.86 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $616.60 / $977.24
| Professional | | $363.08 | $616.60 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $95.50 / $151.36
| Professional | 26 | $54.95 | $95.50 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $549.54 / $794.33
| Professional | | $398.11 | $549.54 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $87.10 / $123.03
| Professional | 26 | $63.10 | $87.10 | $123.03 |