- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $118.59 / $286.98 / $701.58
| Facility | 26 | $118.59 | $286.98 | $701.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.00 / $425.00 / $475.00
| Professional | | $400.00 | $425.00 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.36 / $448.20 / $748.85
| Professional | | $445.36 | $448.20 | $748.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.22 / $624.87 / $1,318.37
| Professional | | $358.22 | $624.87 | $1,318.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.08 / $345.73 / $670.36
| Professional | | $290.08 | $345.73 | $670.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $110.32 / $127.74 / $241.30
| Professional | 26 | $110.32 | $127.74 | $241.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.11 / $459.17 / $1,032.70
| Professional | | $306.11 | $459.17 | $1,032.70 |