- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $457.09 / $478.63 / $537.03
| Facility | 26 | $457.09 | $478.63 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $1,905.46
| Professional | | $933.25 | $1,174.90 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $1,995.26
| Professional | | $1,047.13 | $1,412.54 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | 26 | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,348.96 / $6,606.93
| Professional | | $1,023.29 | $1,348.96 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $1,819.70
| Professional | | $1,071.52 | $1,348.96 | $1,819.70 |