- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $128.00 / $128.00 / $128.00
| Facility | 26 | $128.00 | $128.00 | $128.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.72 / $475.00 / $1,803.93
| Professional | | $291.72 | $475.00 | $1,803.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.70 / $453.13 / $1,091.64
| Professional | | $271.70 | $453.13 | $1,091.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.09 / $147.33 / $263.94
| Professional | | $80.09 | $147.33 | $263.94 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $418.84 / $418.84 / $418.84
| Facility | 26 | $418.84 | $418.84 | $418.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.33 / $496.35 / $643.47
| Professional | | $425.33 | $496.35 | $643.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.39 / $381.79 / $648.72
| Professional | | $276.39 | $381.79 | $648.72 |