- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $142.04 / $156.24 / $156.24
| Facility | 26 | $142.04 | $156.24 | $156.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.00 / $427.88 / $558.34
| Professional | | $400.00 | $427.88 | $558.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.44 / $157.44 / $157.44
| Professional | | $157.44 | $157.44 | $157.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $159.58 / $159.58 / $159.58
| Facility | 26 | $159.58 | $159.58 | $159.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.53 / $873.97 / $3,203.92
| Professional | | $369.53 | $873.97 | $3,203.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.92 / $869.48 / $1,662.67
| Professional | | $354.92 | $869.48 | $1,662.67 |