- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $253.67 / $279.56 / $776.55
| Facility | 26 | $253.67 | $279.56 | $776.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.15 / $1,070.24 / $1,981.93
| Professional | | $971.15 | $1,070.24 | $1,981.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.98 / $1,322.45 / $2,133.28
| Professional | | $986.98 | $1,322.45 | $2,133.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.80 / $1,485.25 / $2,246.04
| Professional | | $1,185.80 | $1,485.25 | $2,246.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,007.36 / $2,442.64 / $2,506.64
| Facility | 26 | $2,007.36 | $2,442.64 | $2,506.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,682.90 / $6,682.90 / $8,154.83
| Professional | | $6,682.90 | $6,682.90 | $8,154.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.83 / $1,441.25 / $2,344.23
| Professional | | $960.83 | $1,441.25 | $2,344.23 |