- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $310.38 / $310.38 / $310.38
| Facility | 26 | $310.38 | $310.38 | $310.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.55 / $1,170.30 / $1,606.90
| Professional | | $1,034.55 | $1,170.30 | $1,606.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.54 / $1,293.58 / $1,915.06
| Professional | | $1,099.54 | $1,293.58 | $1,915.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.10 / $1,587.77 / $2,311.30
| Professional | | $1,336.10 | $1,587.77 | $2,311.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.32 / $1,189.20 / $1,850.40
| Professional | | $1,068.32 | $1,189.20 | $1,850.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.17 / $1,170.29 / $1,696.90
| Professional | | $1,052.17 | $1,170.29 | $1,696.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.58 / $1,465.89 / $2,017.27
| Professional | | $1,069.58 | $1,465.89 | $2,017.27 |