- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | 26 | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,071.52 / $1,778.28
| Professional | | $954.99 | $1,071.52 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $2,511.89
| Professional | | $851.14 | $1,348.96 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,513.56 / $1,862.09
| Professional | | $1,318.26 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $1,905.46
| Professional | | $1,202.26 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $2,089.30
| Professional | | $1,023.29 | $1,230.27 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,412.54 / $1,995.26
| Professional | | $1,071.52 | $1,412.54 | $1,995.26 |