- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $254.70 / $254.70 / $499.30
| Facility | 26 | $254.70 | $254.70 | $499.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.03 / $1,034.55 / $2,252.98
| Professional | | $980.03 | $1,034.55 | $2,252.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.79 / $1,625.39 / $3,195.10
| Professional | | $1,055.79 | $1,625.39 | $3,195.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.06 / $1,708.00 / $2,970.59
| Professional | | $1,160.06 | $1,708.00 | $2,970.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.82 / $1,309.45 / $3,541.00
| Professional | | $1,107.82 | $1,309.45 | $3,541.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $320.33 / $373.72 / $1,062.30
| Professional | 26 | $320.33 | $373.72 | $1,062.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.18 / $1,459.05 / $2,870.24
| Professional | | $1,063.18 | $1,459.05 | $2,870.24 |