- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $131.83 / $194.98 / $194.98
| Facility | 26 | $131.83 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $436.52 / $812.83
| Professional | | $269.15 | $436.52 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $501.19 / $954.99
| Professional | | $223.87 | $501.19 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $141.25
| Professional | | $32.36 | $33.11 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $398.11 / $1,000.00
| Professional | | $269.15 | $398.11 | $1,000.00 |