- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $575.08 / $616.63 / $805.10
| Facility | 26 | $575.08 | $616.63 | $805.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.24 / $1,603.80 / $2,252.69
| Professional | | $1,260.24 | $1,603.80 | $2,252.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,992.73 / $1,992.73 / $1,992.73
| Professional | | $1,992.73 | $1,992.73 | $1,992.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.88 / $2,001.00 / $2,990.34
| Professional | | $1,477.88 | $2,001.00 | $2,990.34 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,974.88 / $2,974.88 / $2,974.88
| Facility | 26 | $2,974.88 | $2,974.88 | $2,974.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,489.14 / $2,089.54 / $9,066.29
| Professional | | $1,489.14 | $2,089.54 | $9,066.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.67 / $2,033.24 / $3,530.97
| Professional | | $1,479.67 | $2,033.24 | $3,530.97 |