- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $305.33 / $305.33 / $458.01
| Facility | 26 | $305.33 | $305.33 | $458.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.29 / $950.12 / $1,279.35
| Professional | | $606.29 | $950.12 | $1,279.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.17 / $1,126.55 / $1,251.72
| Professional | | $851.17 | $1,126.55 | $1,251.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.92 / $1,305.70 / $1,853.91
| Professional | | $1,014.92 | $1,305.70 | $1,853.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.53 / $999.09 / $1,594.32
| Professional | | $802.53 | $999.09 | $1,594.32 |