- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $89.13 / $89.13
| Facility | 26 | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $190.55 / $389.05
| Professional | | $141.25 | $190.55 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $100.00 / $199.53
| Professional | 26 | $79.43 | $100.00 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $616.60 / $616.60
| Professional | | $398.11 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $234.42 / $363.08 / $363.08
| Professional | 26 | $234.42 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $331.13 / $501.19
| Professional | | $229.09 | $331.13 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $151.36 / $263.03
| Professional | 26 | $100.00 | $151.36 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $323.59 / $812.83
| Professional | | $251.19 | $323.59 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $173.78 / $288.40
| Professional | 26 | $87.10 | $173.78 | $288.40 |