- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $245.77 / $245.77 / $245.77
| Facility | 26 | $245.77 | $245.77 | $245.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.34 / $865.31 / $1,731.46
| Professional | | $757.34 | $865.31 | $1,731.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.69 / $819.59 / $1,024.49
| Professional | | $614.69 | $819.59 | $1,024.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.72 / $961.50 / $1,532.46
| Professional | | $793.72 | $961.50 | $1,532.46 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $944.64 / $944.64 / $1,180.80
| Facility | 26 | $944.64 | $944.64 | $1,180.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.93 / $903.62 / $1,928.52
| Professional | | $753.93 | $903.62 | $1,928.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.14 / $866.16 / $1,348.21
| Professional | | $742.14 | $866.16 | $1,348.21 |