- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $131.93 / $145.12 / $145.12
| Facility | 26 | $131.93 | $145.12 | $145.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.55 / $860.72 / $944.88
| Professional | | $827.55 | $860.72 | $944.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.40 / $1,157.41 / $1,626.37
| Professional | | $245.40 | $1,157.41 | $1,626.37 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $146.22 / $146.22 / $146.22
| Facility | 26 | $146.22 | $146.22 | $146.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.13 / $1,099.99 / $3,819.80
| Professional | | $797.13 | $1,099.99 | $3,819.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.84 / $891.04 / $1,549.16
| Professional | | $607.84 | $891.04 | $1,549.16 |