- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $406.31 / $406.31 / $406.31
| Facility | 26 | $406.31 | $406.31 | $406.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.97 / $1,451.98 / $2,292.90
| Professional | | $1,370.97 | $1,451.98 | $2,292.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,523.92 / $3,034.67 / $3,357.19
| Professional | | $2,523.92 | $3,034.67 | $3,357.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.17 / $2,542.77 / $4,104.52
| Professional | | $1,906.17 | $2,542.77 | $4,104.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.20 / $2,663.66 / $3,493.70
| Professional | | $1,513.20 | $2,663.66 | $3,493.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.77 / $2,751.28 / $3,493.70
| Professional | | $1,650.77 | $2,751.28 | $3,493.70 |