- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $118.59 / $276.31 / $601.10
| Facility | 26 | $118.59 | $276.31 | $601.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $425.00
| Professional | | $400.00 | $400.00 | $425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.52 / $485.33 / $1,756.65
| Professional | | $472.52 | $485.33 | $1,756.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.64 / $692.02 / $1,280.71
| Professional | | $381.64 | $692.02 | $1,280.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.00 / $652.84 / $652.84
| Professional | | $291.00 | $652.84 | $652.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $76.73 / $168.17 / $168.17
| Professional | 26 | $76.73 | $168.17 | $168.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.69 / $447.50 / $1,017.47
| Professional | | $255.69 | $447.50 | $1,017.47 |