- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $113.85 / $113.85 / $115.99
| Facility | 26 | $113.85 | $113.85 | $115.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.02 / $377.45 / $474.08
| Professional | | $270.02 | $377.45 | $474.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.00 / $2,062.00 / $2,062.00
| Professional | | $1,255.00 | $2,062.00 | $2,062.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.22 / $727.56 / $1,530.67
| Professional | | $468.22 | $727.56 | $1,530.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.65 / $981.56 / $1,635.93
| Professional | | $488.65 | $981.56 | $1,635.93 |