- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $595.91 / $595.91 / $1,012.84
| Facility | 26 | $595.91 | $595.91 | $1,012.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.25 / $1,973.87 / $4,203.01
| Professional | | $1,789.25 | $1,973.87 | $4,203.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.31 / $3,172.76 / $3,596.14
| Professional | | $1,309.31 | $3,172.76 | $3,596.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.24 / $2,256.69 / $4,074.54
| Professional | | $1,712.24 | $2,256.69 | $4,074.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.26 / $1,873.26 / $2,195.67
| Professional | | $1,873.26 | $1,873.26 | $2,195.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.85 / $2,189.78 / $5,036.50
| Professional | | $1,459.85 | $2,189.78 | $5,036.50 |