- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $287.35 / $287.35 / $490.46
| Facility | 26 | $287.35 | $287.35 | $490.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.15 / $916.50 / $1,540.88
| Professional | | $878.15 | $916.50 | $1,540.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.04 / $1,903.41 / $2,248.89
| Professional | | $1,766.04 | $1,903.41 | $2,248.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.14 / $1,572.82 / $2,420.30
| Professional | | $1,031.14 | $1,572.82 | $2,420.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.45 / $1,755.28 / $5,608.27
| Professional | | $922.45 | $1,755.28 | $5,608.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.45 / $1,662.89 / $2,305.36
| Professional | | $922.45 | $1,662.89 | $2,305.36 |