- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $234.42 / $234.42
| Facility | 26 | $117.49 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,023.29 / $1,659.59
| Professional | | $707.95 | $1,023.29 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $831.76 / $1,000.00
| Professional | | $588.84 | $831.76 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $1,412.54
| Professional | | $758.58 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,258.93
| Professional | | $602.56 | $812.83 | $1,258.93 |