- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.15 / $102.15 / $102.15
| Facility | 26 | $102.15 | $102.15 | $102.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.88 / $786.64 / $1,483.77
| Professional | | $598.88 | $786.64 | $1,483.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.74 / $700.93 / $1,376.52
| Professional | | $141.74 | $700.93 | $1,376.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.66 / $1,173.52 / $1,530.85
| Professional | | $839.66 | $1,173.52 | $1,530.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $201.47 / $1,191.58
| Professional | | $32.34 | $201.47 | $1,191.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.66 / $1,173.52 / $1,530.85
| Professional | | $839.66 | $1,173.52 | $1,530.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.91 / $1,235.84 / $1,900.73
| Professional | | $964.91 | $1,235.84 | $1,900.73 |