- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $267.94 / $279.56 / $486.45
| Facility | 26 | $267.94 | $279.56 | $486.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.28 / $1,034.55 / $1,925.87
| Professional | | $958.28 | $1,034.55 | $1,925.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,037.00 / $2,037.00 / $2,037.00
| Professional | | $2,037.00 | $2,037.00 | $2,037.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.61 / $1,422.67 / $1,746.35
| Professional | | $931.61 | $1,422.67 | $1,746.35 |
- 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
- $926.92 / $1,194.49 / $2,714.95
| Professional | | $926.92 | $1,194.49 | $2,714.95 |