- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $522.73 / $522.73 / $522.73
| Facility | 26 | $522.73 | $522.73 | $522.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.76 / $640.30 / $1,087.28
| Professional | | $580.76 | $640.30 | $1,087.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $181.68 / $212.97 / $380.58
| Professional | 26 | $181.68 | $212.97 | $380.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.13 / $940.15 / $1,133.71
| Professional | | $733.13 | $940.15 | $1,133.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $246.96 / $323.54 / $390.16
| Professional | 26 | $246.96 | $323.54 | $390.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.45 / $1,039.86 / $1,406.12
| Professional | | $980.45 | $1,039.86 | $1,406.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $322.91 / $342.48 / $391.40
| Professional | 26 | $322.91 | $342.48 | $391.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $364.05 / $1,066.26
| Professional | | $32.34 | $364.05 | $1,066.26 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,374.41 / $1,374.41 / $1,374.41
| Facility | 26 | $1,374.41 | $1,374.41 | $1,374.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.09 / $1,244.65 / $1,406.12
| Professional | | $1,141.09 | $1,244.65 | $1,406.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $377.82 / $406.89 / $485.84
| Professional | 26 | $377.82 | $406.89 | $485.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.86 / $754.58 / $1,209.79
| Professional | | $644.86 | $754.58 | $1,209.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $216.60 / $248.39 / $398.25
| Professional | 26 | $216.60 | $248.39 | $398.25 |