- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $144.71 / $144.71 / $185.18
| Facility | 26 | $144.71 | $144.71 | $185.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.00 / $808.58 / $981.44
| Professional | | $794.00 | $808.58 | $981.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.49 / $1,797.07 / $2,952.48
| Professional | | $868.49 | $1,797.07 | $2,952.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.93 / $2,081.85 / $3,165.21
| Professional | | $1,220.93 | $2,081.85 | $3,165.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.88 / $1,863.92 / $3,227.87
| Professional | | $951.88 | $1,863.92 | $3,227.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.20 / $1,526.21 / $2,687.96
| Professional | | $1,164.20 | $1,526.21 | $2,687.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.68 / $822.82 / $1,209.54
| Professional | | $685.68 | $822.82 | $1,209.54 |