- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $307.47 / $307.47 / $476.48
| Facility | 26 | $307.47 | $307.47 | $476.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.46 / $1,111.75 / $1,280.82
| Professional | | $941.46 | $1,111.75 | $1,280.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.00 / $1,574.75 / $3,472.89
| Professional | | $1,093.00 | $1,574.75 | $3,472.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.61 / $1,615.48 / $1,797.83
| Professional | | $1,466.61 | $1,615.48 | $1,797.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.48 / $990.73 / $1,321.24
| Professional | | $735.48 | $990.73 | $1,321.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.31 / $1,261.38 / $2,427.08
| Professional | | $902.31 | $1,261.38 | $2,427.08 |