- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $497.39 / $497.39 / $497.40
| Facility | 26 | $497.39 | $497.39 | $497.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.15 / $1,739.80 / $1,791.48
| Professional | | $971.15 | $1,739.80 | $1,791.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.34 / $1,595.00 / $1,909.60
| Professional | | $1,164.34 | $1,595.00 | $1,909.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.20 / $1,411.84 / $3,137.35
| Professional | | $1,097.20 | $1,411.84 | $3,137.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.50 / $1,069.58 / $1,565.55
| Professional | | $745.50 | $1,069.58 | $1,565.55 |