- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Facility | 26 | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $363.08 / $1,258.93
| Professional | | $295.12 | $363.08 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.12 / $72.44 / $234.42
| Professional | 26 | $50.12 | $72.44 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $302.00 / $724.44
| Professional | | $257.04 | $302.00 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.98 / $57.54 / $131.83
| Professional | 26 | $48.98 | $57.54 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $758.58 / $776.25
| Professional | | $416.87 | $758.58 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $131.83 / $141.25
| Professional | 26 | $79.43 | $131.83 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $316.23 / $575.44
| Professional | | $213.80 | $316.23 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $61.66 / $72.44 / $104.71
| Professional | 26 | $61.66 | $72.44 | $104.71 |