- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $229.09 / $229.09 / $269.15
| Facility | 26 | $229.09 | $229.09 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $616.60 / $1,479.11
| Professional | | $478.63 | $616.60 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $162.18 / $194.98 / $512.86
| Professional | 26 | $162.18 | $194.98 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $676.08 / $954.99
| Professional | | $489.78 | $676.08 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $158.49 / $218.78 / $309.03
| Professional | 26 | $158.49 | $218.78 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Professional | 26 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $602.56 / $1,348.96
| Professional | | $478.63 | $602.56 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $154.88 / $199.53 / $446.68
| Professional | 26 | $154.88 | $199.53 | $446.68 |