- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.57 / $128.82 / $331.13
| Facility | 26 | $64.57 | $128.82 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $245.47 / $562.34
| Professional | | $173.78 | $245.47 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $77.62 / $77.62 / $77.62
| Facility | 26 | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $295.12 / $602.56
| Professional | | $194.98 | $295.12 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $16.60 / $89.13 / $218.78
| Facility | 26 | $16.60 | $89.13 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $331.13 / $645.65
| Professional | | $190.55 | $331.13 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $446.68 / $1,000.00
| Professional | | $213.80 | $446.68 | $1,000.00 |