- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $105.52 / $340.29 / $890.06
| Facility | 26 | $105.52 | $340.29 | $890.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.58 / $280.62 / $300.00
| Professional | | $260.58 | $280.62 | $300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.38 / $631.52 / $955.98
| Professional | | $579.38 | $631.52 | $955.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.83 / $733.64 / $2,267.35
| Professional | | $460.83 | $733.64 | $2,267.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.42 / $583.76 / $1,135.09
| Professional | | $486.42 | $583.76 | $1,135.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $119.20 / $138.02 / $260.04
| Professional | 26 | $119.20 | $138.02 | $260.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.30 / $780.68 / $1,722.92
| Professional | | $457.30 | $780.68 | $1,722.92 |