- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,724.19 / $1,724.19 / $1,724.19
| Facility | 26 | $1,724.19 | $1,724.19 | $1,724.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.29 / $840.21 / $1,028.83
| Professional | | $606.29 | $840.21 | $1,028.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.18 / $1,101.24 / $1,940.70
| Professional | | $968.18 | $1,101.24 | $1,940.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.11 / $1,851.07 / $2,553.54
| Professional | | $1,147.11 | $1,851.07 | $2,553.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.52 / $1,263.43 / $1,539.36
| Professional | | $829.52 | $1,263.43 | $1,539.36 |