- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $131.86 / $131.86 / $131.86
| Facility | 26 | $131.86 | $131.86 | $131.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.58 / $973.70 / $1,162.66
| Professional | | $741.58 | $973.70 | $1,162.66 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $101.65 / $101.65 / $101.65
| Facility | 26 | $101.65 | $101.65 | $101.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.38 / $1,999.95 / $3,105.14
| Professional | | $1,196.38 | $1,999.95 | $3,105.14 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $297.32 / $421.64 / $1,014.30
| Facility | 26 | $297.32 | $421.64 | $1,014.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.97 / $2,675.78 / $3,609.94
| Professional | | $1,659.97 | $2,675.78 | $3,609.94 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $241.70 / $385.48 / $798.66
| Facility | 26 | $241.70 | $385.48 | $798.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.21 / $2,252.15 / $3,211.00
| Professional | | $1,403.21 | $2,252.15 | $3,211.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.14 / $1,845.85 / $3,153.86
| Professional | | $1,020.14 | $1,845.85 | $3,153.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.04 / $1,791.85 / $3,020.36
| Professional | | $1,061.04 | $1,791.85 | $3,020.36 |