- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $114.82 / $288.40
| Facility | 26 | $57.54 | $114.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $354.81 / $851.14
| Professional | | $281.84 | $354.81 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.12 / $67.61 / $158.49
| Professional | 26 | $50.12 | $67.61 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $389.05 / $794.33
| Professional | | $269.15 | $389.05 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $87.10 / $158.49
| Professional | 26 | $63.10 | $87.10 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $15.85 / $89.13 / $281.84
| Facility | 26 | $15.85 | $89.13 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $512.86 / $1,000.00
| Professional | | $275.42 | $512.86 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $102.33 / $190.55
| Professional | 26 | $57.54 | $102.33 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $389.05 / $812.83
| Professional | | $269.15 | $389.05 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $75.86 / $147.91
| Professional | 26 | $56.23 | $75.86 | $147.91 |