- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $365.31 / $365.31 / $365.31
| Facility | 26 | $365.31 | $365.31 | $365.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.42 / $804.12 / $859.47
| Professional | | $683.42 | $804.12 | $859.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $365.31 / $412.78 / $546.23
| Professional | 26 | $365.31 | $412.78 | $546.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $523.61 / $523.61 / $523.61
| Facility | 26 | $523.61 | $523.61 | $523.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.10 / $1,161.73 / $4,374.82
| Professional | | $767.10 | $1,161.73 | $4,374.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $520.73 / $607.52 / $2,572.55
| Professional | 26 | $520.73 | $607.52 | $2,572.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.32 / $803.14 / $1,548.09
| Professional | | $527.32 | $803.14 | $1,548.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $368.38 / $581.14 / $1,179.28
| Professional | 26 | $368.38 | $581.14 | $1,179.28 |