- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.07 / $77.59 / $96.98
| Facility | 26 | $32.07 | $77.59 | $96.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.46 / $196.00 / $1,156.81
| Professional | | $185.46 | $196.00 | $1,156.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.66 / $210.22 / $1,018.27
| Professional | | $157.66 | $210.22 | $1,018.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.44 / $245.93 / $387.81
| Professional | | $153.44 | $245.93 | $387.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $54.18 / $122.00 / $122.00
| Facility | 26 | $54.18 | $122.00 | $122.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.88 / $175.83 / $1,203.75
| Professional | | $146.88 | $175.83 | $1,203.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.88 / $172.56 / $328.33
| Professional | | $146.88 | $172.56 | $328.33 |