- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $95.79 / $95.79 / $97.57
| Facility | 26 | $95.79 | $95.79 | $97.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.94 / $458.11 / $475.00
| Professional | | $268.94 | $458.11 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.00 / $1,479.00 / $2,732.00
| Professional | | $900.00 | $1,479.00 | $2,732.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.63 / $596.37 / $1,119.33
| Professional | | $409.63 | $596.37 | $1,119.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.08 / $688.59 / $2,295.14
| Professional | | $612.08 | $688.59 | $2,295.14 |