- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.76 / $292.23 / $327.77
| Facility | 26 | $120.76 | $292.23 | $327.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.60 / $887.60 / $2,409.17
| Professional | | $887.60 | $887.60 | $2,409.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.30 / $1,000.34 / $3,784.13
| Professional | | $884.30 | $1,000.34 | $3,784.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.22 / $1,063.75 / $3,969.26
| Professional | | $855.22 | $1,063.75 | $3,969.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,033.39 / $2,033.39 / $2,033.39
| Professional | | $2,033.39 | $2,033.39 | $2,033.39 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $284.02 / $284.02 / $284.02
| Professional | 26 | $284.02 | $284.02 | $284.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.43 / $1,300.68 / $2,052.71
| Professional | | $832.43 | $1,300.68 | $2,052.71 |