- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $216.72 / $216.72 / $216.72
| Facility | 26 | $216.72 | $216.72 | $216.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.45 / $1,034.55 / $1,422.45
| Professional | | $685.45 | $1,034.55 | $1,422.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.02 / $941.21 / $1,629.14
| Professional | | $289.02 | $941.21 | $1,629.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.77 / $1,470.65 / $1,901.37
| Professional | | $1,047.77 | $1,470.65 | $1,901.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $428.80 / $1,421.31
| Professional | | $32.34 | $428.80 | $1,421.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.50 / $1,470.65 / $1,901.37
| Professional | | $1,127.50 | $1,470.65 | $1,901.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.30 / $1,623.04 / $2,390.30
| Professional | | $1,303.30 | $1,623.04 | $2,390.30 |