- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $128.96 / $128.96 / $128.96
| Facility | 26 | $128.96 | $128.96 | $128.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.58 / $855.25 / $1,389.38
| Professional | | $741.58 | $855.25 | $1,389.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.58 / $1,895.22 / $2,113.79
| Professional | | $1,578.58 | $1,895.22 | $2,113.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.81 / $1,614.15 / $2,605.54
| Professional | | $1,053.81 | $1,614.15 | $2,605.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.99 / $1,457.34 / $2,064.81
| Professional | | $863.99 | $1,457.34 | $2,064.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.40 / $1,529.26 / $2,064.81
| Professional | | $874.40 | $1,529.26 | $2,064.81 |