- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $105.14 / $105.14 / $190.02
| Facility | 26 | $105.14 | $105.14 | $190.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.65 / $698.66 / $963.37
| Professional | | $698.65 | $698.66 | $963.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.01 / $834.05 / $1,145.27
| Professional | | $158.01 | $834.05 | $1,145.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.38 / $1,046.72 / $1,226.77
| Professional | | $776.38 | $1,046.72 | $1,226.77 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $944.64 / $1,180.80 / $1,180.80
| Facility | 26 | $944.64 | $1,180.80 | $1,180.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.81 / $990.13 / $5,824.33
| Professional | | $732.81 | $990.13 | $5,824.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.19 / $907.19 / $1,477.42
| Professional | | $691.19 | $907.19 | $1,477.42 |