- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $400.80 / $400.80 / $683.03
| Facility | 26 | $400.80 | $400.80 | $683.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.55 / $1,402.17 / $2,156.88
| Professional | | $1,034.55 | $1,402.17 | $2,156.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.89 / $2,266.98 / $2,623.58
| Professional | | $929.89 | $2,266.98 | $2,623.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.80 / $1,613.23 / $2,973.98
| Professional | | $1,252.80 | $1,613.23 | $2,973.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.79 / $1,338.79 / $1,615.48
| Professional | | $1,338.79 | $1,338.79 | $1,615.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.61 / $1,720.89 / $3,628.57
| Professional | | $1,168.61 | $1,720.89 | $3,628.57 |