- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $174.60 / $174.60 / $174.60
| Facility | 26 | $174.60 | $174.60 | $174.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.24 / $866.29 / $1,192.56
| Professional | | $830.24 | $866.29 | $1,192.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.98 / $1,214.30 / $1,479.74
| Professional | | $987.98 | $1,214.30 | $1,479.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.48 / $545.62 / $805.23
| Professional | | $79.48 | $545.62 | $805.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $5,276.22 / $5,276.22 / $5,276.22
| Facility | 26 | $5,276.22 | $5,276.22 | $5,276.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.50 / $1,803.36 / $1,980.83
| Professional | | $1,481.50 | $1,803.36 | $1,980.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.98 / $863.99 / $1,444.55
| Professional | | $763.98 | $863.99 | $1,444.55 |