- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $265.58 / $265.58 / $1,133.48
| Facility | 26 | $265.58 | $265.58 | $1,133.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.04 / $923.57 / $1,172.79
| Professional | | $785.04 | $923.57 | $1,172.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.54 / $1,189.22 / $2,133.35
| Professional | | $746.54 | $1,189.22 | $2,133.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.97 / $1,275.00 / $1,275.00
| Professional | | $1,070.97 | $1,275.00 | $1,275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.60 / $928.00 / $1,356.93
| Professional | | $763.60 | $928.00 | $1,356.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.00 / $1,061.94 / $1,805.77
| Professional | | $714.00 | $1,061.94 | $1,805.77 |