- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $190.50 / $231.43 / $319.30
| Facility | 26 | $190.50 | $231.43 | $319.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.18 / $707.88 / $1,060.23
| Professional | | $494.18 | $707.88 | $1,060.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.35 / $1,016.35 / $1,016.35
| Professional | | $1,016.35 | $1,016.35 | $1,016.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.19 / $739.94 / $1,284.48
| Professional | | $397.19 | $739.94 | $1,284.48 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,014.88 / $1,307.92 / $1,307.92
| Facility | 26 | $1,014.88 | $1,307.92 | $1,307.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.16 / $839.33 / $4,924.22
| Professional | | $508.16 | $839.33 | $4,924.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.25 / $808.40 / $1,059.40
| Professional | | $505.25 | $808.40 | $1,059.40 |