- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $223.86 / $223.86 / $223.86
| Facility | 26 | $223.86 | $223.86 | $223.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.03 / $813.03 / $1,138.01
| Professional | | $813.03 | $813.03 | $1,138.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.59 / $1,243.94 / $1,365.87
| Professional | | $336.59 | $1,243.94 | $1,365.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.72 / $1,302.34 / $1,555.28
| Professional | | $965.72 | $1,302.34 | $1,555.28 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,007.36 / $2,506.64 / $2,506.64
| Facility | 26 | $2,007.36 | $2,506.64 | $2,506.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.25 / $1,224.75 / $6,682.90
| Professional | | $905.25 | $1,224.75 | $6,682.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.00 / $1,135.38 / $1,685.89
| Professional | | $852.00 | $1,135.38 | $1,685.89 |