- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $295.12 / $407.38 / $512.86
| Facility | 26 | $295.12 | $407.38 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $1,230.27
| Professional | | $933.25 | $1,071.52 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,511.89 / $3,548.13
| Professional | | $977.24 | $2,511.89 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,454.71 / $3,801.89
| Professional | | $1,445.44 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,995.26 / $3,311.31
| Professional | | $1,148.15 | $1,995.26 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $3,801.89
| Professional | | $1,445.44 | $1,995.26 | $3,801.89 |