- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $125.89 / $173.78 / $281.84
| Facility | 26 | $125.89 | $173.78 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $954.99 / $1,905.46
| Professional | | $741.31 | $954.99 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,174.90 / $2,454.71
| Professional | | $645.65 | $1,174.90 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.90 / $186.21 / $588.84
| Facility | 26 | $30.90 | $186.21 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,288.25 / $2,818.38
| Professional | | $870.96 | $1,288.25 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $1,995.26
| Professional | | $741.31 | $1,071.52 | $1,995.26 |