- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $274.81 / $274.81 / $281.07
| Facility | 26 | $274.81 | $274.81 | $281.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.94 / $885.94 / $898.24
| Professional | | $885.94 | $885.94 | $898.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.00 / $3,318.00 / $3,318.00
| Professional | | $1,850.00 | $3,318.00 | $3,318.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.92 / $1,335.75 / $3,222.92
| Professional | | $1,200.92 | $1,335.75 | $3,222.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.01 / $1,533.60 / $2,833.61
| Professional | | $1,096.01 | $1,533.60 | $2,833.61 |