- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Facility | 26 | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,122.02 / $3,162.28
| Professional | | $954.99 | $1,122.02 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $588.84 / $660.69 / $2,454.71
| Facility | 26 | $588.84 | $660.69 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,584.89 / $4,466.84
| Professional | | $794.33 | $1,584.89 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,238.72 / $3,715.35
| Professional | | $1,318.26 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $676.08 / $1,513.56
| Professional | | $199.53 | $676.08 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,778.28 / $3,548.13
| Professional | | $1,000.00 | $1,778.28 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $588.84 / $660.69 / $2,454.71
| Facility | 26 | $588.84 | $660.69 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,584.89 / $4,466.84
| Professional | | $794.33 | $1,584.89 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $4,073.80
| Professional | | $1,230.27 | $1,862.09 | $4,073.80 |