- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $107.15 / $117.49
| Facility | 26 | $58.88 | $107.15 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $123.03 / $213.80
| Professional | | $100.00 | $123.03 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Professional | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $199.53 / $537.03
| Professional | | $93.33 | $199.53 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $123.03 / $123.03 / $245.47
| Facility | 26 | $123.03 | $123.03 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $269.15 / $3,090.30
| Professional | | $128.82 | $269.15 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $190.55 / $549.54
| Professional | | $125.89 | $190.55 | $549.54 |