- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $232.27 / $379.66 / $624.67
| Facility | 26 | $232.27 | $379.66 | $624.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.51 / $871.61 / $2,470.75
| Professional | | $730.51 | $871.61 | $2,470.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.21 / $1,030.26 / $1,679.56
| Professional | | $833.21 | $1,030.26 | $1,679.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.94 / $1,228.45 / $1,896.23
| Professional | | $868.94 | $1,228.45 | $1,896.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $662.35 / $1,291.31 / $1,291.31
| Facility | 26 | $662.35 | $1,291.31 | $1,291.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.88 / $1,090.73 / $5,608.27
| Professional | | $888.88 | $1,090.73 | $5,608.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.88 / $1,083.97 / $2,016.38
| Professional | | $888.88 | $1,083.97 | $2,016.38 |