- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Facility | 26 | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,122.02 / $2,398.83
| Professional | | $891.25 | $1,122.02 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $676.08 / $1,445.44
| Professional | | $288.40 | $676.08 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,621.81 / $1,905.46
| Professional | | $1,174.90 | $1,621.81 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $1,380.38
| Professional | | $32.36 | $33.11 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $1,905.46
| Professional | | $1,122.02 | $1,479.11 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,621.81 / $2,089.30
| Professional | | $1,174.90 | $1,621.81 | $2,089.30 |