- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $151.36 / $186.21 / $229.09
| Facility | 26 | $151.36 | $186.21 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $2,630.27
| Professional | | $758.58 | $977.24 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $3,019.95
| Professional | | $891.25 | $1,258.93 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $1,621.81
| Professional | | $1,047.13 | $1,348.96 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,995.26
| Professional | | $724.44 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $1,995.26
| Professional | | $758.58 | $1,000.00 | $1,995.26 |