- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $288.40 / $371.54 / $457.09
| Facility | 26 | $288.40 | $371.54 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,174.90 / $2,398.83
| Professional | | $954.99 | $1,174.90 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $2,041.74
| Professional | | $1,148.15 | $1,445.44 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,584.89 / $2,089.30
| Professional | | $1,258.93 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $1,862.09
| Professional | | $1,445.44 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $380.19 / $562.34 / $562.34
| Professional | 26 | $380.19 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,023.29 / $1,096.48
| Professional | | $954.99 | $1,023.29 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $2,511.89
| Professional | | $1,258.93 | $1,621.81 | $2,511.89 |