- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $79.01 / $136.02 / $173.49
| Facility | 26 | $79.01 | $136.02 | $173.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.27 / $839.09 / $1,259.73
| Professional | | $569.27 | $839.09 | $1,259.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.00 / $857.00 / $857.00
| Professional | | $857.00 | $857.00 | $857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.52 / $1,081.32 / $1,526.57
| Professional | | $643.52 | $1,081.32 | $1,526.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.69 / $763.28 / $1,590.18
| Professional | | $540.69 | $763.28 | $1,590.18 |