- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Facility | 26 | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $229.09 / $724.44
| Professional | | $117.49 | $229.09 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $45.71 / $112.20 / $524.81
| Professional | 26 | $45.71 | $112.20 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $213.80 / $380.19
| Professional | | $158.49 | $213.80 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $109.65 / $151.36
| Professional | 26 | $81.28 | $109.65 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $309.03 / $537.03
| Professional | | $134.90 | $309.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.98 / $114.82 / $204.17
| Professional | 26 | $48.98 | $114.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $257.04 / $588.84
| Professional | | $186.21 | $257.04 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $51.29 / $100.00 / $181.97
| Professional | 26 | $51.29 | $100.00 | $181.97 |