- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $133.53 / $133.53 / $133.53
| Facility | 26 | $133.53 | $133.53 | $133.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.68 / $451.75 / $475.00
| Professional | | $277.68 | $451.75 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.85 / $200.18 / $429.46
| Professional | | $132.85 | $200.18 | $429.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.67 / $468.52 / $770.00
| Professional | | $268.67 | $468.52 | $770.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.73 / $430.03 / $1,075.22
| Professional | | $303.73 | $430.03 | $1,075.22 |