- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $232.53 / $451.70 / $470.41
| Facility | 26 | $232.53 | $451.70 | $470.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.30 / $1,327.33 / $1,382.31
| Professional | | $683.30 | $1,327.33 | $1,382.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,586.00 / $1,586.00 / $1,586.00
| Professional | | $1,586.00 | $1,586.00 | $1,586.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.75 / $1,231.93 / $1,615.22
| Professional | | $740.75 | $1,231.93 | $1,615.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.96 / $986.52 / $1,894.90
| Professional | | $737.96 | $986.52 | $1,894.90 |