- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $194.89 / $194.89 / $199.37
| Facility | 26 | $194.89 | $194.89 | $199.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.79 / $592.79 / $604.11
| Professional | | $592.79 | $592.79 | $604.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $194.89 / $194.89 / $200.06
| Professional | 26 | $194.89 | $194.89 | $200.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.00 / $2,229.00 / $2,229.00
| Professional | | $1,242.00 | $2,229.00 | $2,229.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $411.00 / $738.00 / $738.00
| Professional | 26 | $411.00 | $738.00 | $738.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.01 / $899.65 / $2,139.65
| Professional | | $786.01 | $899.65 | $2,139.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $259.60 / $312.70 / $717.69
| Professional | 26 | $259.60 | $312.70 | $717.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.34 / $1,018.20 / $1,854.61
| Professional | | $717.34 | $1,018.20 | $1,854.61 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $236.14 / $353.40 / $617.13
| Professional | 26 | $236.14 | $353.40 | $617.13 |