- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $475.28 / $475.28 / $475.28
| Facility | 26 | $475.28 | $475.28 | $475.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.30 / $1,427.87 / $1,427.87
| Professional | | $683.30 | $1,427.87 | $1,427.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.25 / $860.61 / $1,015.52
| Professional | | $628.25 | $860.61 | $1,015.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.06 / $1,066.03 / $2,852.49
| Professional | | $823.06 | $1,066.03 | $2,852.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.39 / $906.08 / $1,210.72
| Professional | | $673.39 | $906.08 | $1,210.72 |