- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $235.48 / $235.48 / $235.48
| Facility | 26 | $235.48 | $235.48 | $235.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $99.35 / $250.00 / $265.00
| Professional | 26 | $99.35 | $250.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.76 / $83.56 / $187.02
| Professional | 26 | $74.76 | $83.56 | $187.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $144.11 / $152.85 / $174.68
| Professional | 26 | $144.11 | $152.85 | $174.68 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,871.86 / $2,871.86 / $2,871.86
| Facility | 26 | $2,871.86 | $2,871.86 | $2,871.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $170.82 / $184.95 / $222.13
| Professional | 26 | $170.82 | $184.95 | $222.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.98 / $100.32 / $183.33
| Professional | 26 | $80.98 | $100.32 | $183.33 |