- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $176.10 / $264.47 / $597.08
| Facility | 26 | $176.10 | $264.47 | $597.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.84 / $471.71 / $525.00
| Professional | | $358.84 | $471.71 | $525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.20 / $507.87 / $732.21
| Professional | | $249.20 | $507.87 | $732.21 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $113.73 / $113.73 / $125.89
| Facility | 26 | $113.73 | $113.73 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.76 / $518.95 / $852.73
| Professional | | $245.76 | $518.95 | $852.73 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,008.32 / $1,008.32 / $1,031.35
| Facility | 26 | $1,008.32 | $1,008.32 | $1,031.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,148.28 / $3,148.28 / $3,148.28
| Professional | | $3,148.28 | $3,148.28 | $3,148.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.01 / $456.83 / $709.10
| Professional | | $299.01 | $456.83 | $709.10 |