- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $365.60 / $365.60 / $460.65
| Facility | 26 | $365.60 | $365.60 | $460.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.03 / $1,192.49 / $1,699.86
| Professional | | $980.03 | $1,192.49 | $1,699.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.55 / $1,083.41 / $1,494.14
| Professional | | $546.55 | $1,083.41 | $1,494.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.40 / $1,424.58 / $2,113.26
| Professional | | $894.40 | $1,424.58 | $2,113.26 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $317.82 / $365.60 / $460.65
| Facility | 26 | $317.82 | $365.60 | $460.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.55 / $1,179.35 / $1,699.86
| Professional | | $1,034.55 | $1,179.35 | $1,699.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.25 / $712.42 / $1,158.18
| Professional | | $252.25 | $712.42 | $1,158.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.35 / $1,306.56 / $1,849.41
| Professional | | $1,062.35 | $1,306.56 | $1,849.41 |