- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $281.84 / $281.84 / $524.81
| Facility | 26 | $281.84 | $281.84 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,905.46
| Professional | | $933.25 | $1,122.02 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $2,290.87
| Professional | | $1,122.02 | $1,479.11 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $2,238.72
| Professional | | $1,174.90 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | 26 | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,128.31 / $8,128.31
| Professional | | $6,606.93 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $2,238.72
| Professional | | $954.99 | $1,380.38 | $2,238.72 |