- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $737.58 / $737.58 / $737.58
| Facility | 26 | $737.58 | $737.58 | $737.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.75 / $1,540.88 / $1,613.91
| Professional | | $888.75 | $1,540.88 | $1,613.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.90 / $1,403.73 / $1,692.74
| Professional | | $1,103.90 | $1,403.73 | $1,692.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.05 / $1,553.84 / $2,091.23
| Professional | | $1,465.05 | $1,553.84 | $2,091.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $513.66 / $1,592.47
| Professional | | $32.34 | $513.66 | $1,592.47 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,374.41 / $1,374.41 / $1,374.41
| Facility | 26 | $1,374.41 | $1,374.41 | $1,374.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.63 / $1,858.41 / $2,091.23
| Professional | | $1,698.63 | $1,858.41 | $2,091.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.28 / $1,152.90 / $1,848.39
| Professional | | $971.28 | $1,152.90 | $1,848.39 |