- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $275.42 / $489.78
| Facility | 26 | $117.49 | $275.42 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $426.58 / $851.14
| Professional | | $275.42 | $426.58 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $467.74 / $2,454.71
| Professional | | $338.84 | $467.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $588.84 / $1,122.02
| Professional | | $346.74 | $588.84 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $338.84 / $660.69
| Professional | | $281.84 | $338.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $77.62 / $89.13 / $169.82
| Professional | 26 | $77.62 | $89.13 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $467.74 / $1,000.00
| Professional | | $269.15 | $467.74 | $1,000.00 |