- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $202.10 / $202.10 / $447.79
| Facility | 26 | $202.10 | $202.10 | $447.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.46 / $1,001.35 / $3,730.40
| Professional | | $630.46 | $1,001.35 | $3,730.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.79 / $619.37 / $1,558.53
| Professional | | $250.79 | $619.37 | $1,558.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.82 / $1,260.22 / $1,570.28
| Professional | | $965.82 | $1,260.22 | $1,570.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $275.76 / $908.14
| Professional | | $32.34 | $275.76 | $908.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.82 / $1,260.22 / $1,570.28
| Professional | | $965.82 | $1,260.22 | $1,570.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.06 / $1,171.56 / $1,798.78
| Professional | | $1,153.06 | $1,171.56 | $1,798.78 |