- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $281.07 / $295.12 / $295.12
| Facility | 26 | $281.07 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.03 / $970.47 / $1,540.88
| Professional | | $835.03 | $970.47 | $1,540.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.27 / $1,307.30 / $2,097.06
| Professional | | $951.27 | $1,307.30 | $2,097.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.48 / $1,338.79 / $1,845.42
| Professional | | $857.48 | $1,338.79 | $1,845.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.47 / $1,460.33 / $1,830.03
| Professional | | $970.47 | $1,460.33 | $1,830.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $295.12 / $444.09 / $556.52
| Professional | 26 | $295.12 | $444.09 | $556.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.34 / $1,515.53 / $2,542.75
| Professional | | $1,161.34 | $1,515.53 | $2,542.75 |