- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $431.35 / $431.35 / $581.90
| Facility | 26 | $431.35 | $431.35 | $581.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.35 / $1,472.35 / $1,477.71
| Professional | | $1,472.35 | $1,472.35 | $1,477.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.47 / $2,877.52 / $4,727.59
| Professional | | $1,493.47 | $2,877.52 | $4,727.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.54 / $3,268.17 / $4,968.87
| Professional | | $1,943.54 | $3,268.17 | $4,968.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.27 / $2,900.88 / $5,168.53
| Professional | | $1,453.27 | $2,900.88 | $5,168.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.84 / $2,590.56 / $4,582.68
| Professional | | $1,984.84 | $2,590.56 | $4,582.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.21 / $1,441.29 / $2,050.35
| Professional | | $1,168.21 | $1,441.29 | $2,050.35 |