- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $310.52 / $310.52 / $310.52
| Facility | 26 | $310.52 | $310.52 | $310.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.02 / $972.78 / $4,073.60
| Professional | | $878.02 | $972.78 | $4,073.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.10 / $1,207.20 / $1,648.50
| Professional | | $1,050.10 | $1,207.20 | $1,648.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.37 / $550.08 / $861.73
| Professional | | $211.37 | $550.08 | $861.73 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,289.40 / $1,289.40 / $1,289.40
| Facility | 26 | $1,289.40 | $1,289.40 | $1,289.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.89 / $1,671.22 / $1,849.57
| Professional | | $1,344.89 | $1,671.22 | $1,849.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.45 / $1,153.06 / $1,522.04
| Professional | | $922.45 | $1,153.06 | $1,522.04 |