- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $375.60 / $1,096.67 / $1,771.54
| Facility | 26 | $375.60 | $1,096.67 | $1,771.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.31 / $1,279.41 / $1,634.44
| Professional | | $726.31 | $1,279.41 | $1,634.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.76 / $1,455.57 / $1,712.00
| Professional | | $859.76 | $1,455.57 | $1,712.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.19 / $1,311.69 / $2,287.62
| Professional | | $1,129.19 | $1,311.69 | $2,287.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.37 / $1,178.31 / $1,236.93
| Professional | | $855.37 | $1,178.31 | $1,236.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.26 / $1,291.43 / $2,157.06
| Professional | | $927.26 | $1,291.43 | $2,157.06 |