- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $387.23 / $447.86 / $542.11
| Facility | 26 | $387.23 | $447.86 | $542.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.91 / $1,179.00 / $1,657.05
| Professional | | $927.91 | $1,179.00 | $1,657.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.88 / $1,345.88 / $1,345.88
| Professional | | $1,345.88 | $1,345.88 | $1,345.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.60 / $1,431.00 / $2,140.36
| Professional | | $1,055.60 | $1,431.00 | $2,140.36 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,007.36 / $2,007.36 / $2,007.36
| Facility | 26 | $2,007.36 | $2,007.36 | $2,007.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.20 / $1,490.85 / $6,682.90
| Professional | | $1,071.20 | $1,490.85 | $6,682.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.00 / $1,447.06 / $2,539.98
| Professional | | $1,065.00 | $1,447.06 | $2,539.98 |