- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $239.88 / $269.15 / $691.83
| Facility | 26 | $239.88 | $269.15 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $2,511.89
| Professional | | $812.83 | $1,096.48 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $234.42 / $346.74 / $588.84
| Professional | 26 | $234.42 | $346.74 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $1,412.54
| Professional | | $891.25 | $1,096.48 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $223.87 / $302.00 / $371.54
| Professional | 26 | $223.87 | $302.00 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $2,089.30
| Professional | | $870.96 | $1,047.13 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $234.42 / $295.12 / $562.34
| Professional | 26 | $234.42 | $295.12 | $562.34 |