- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $274.85 / $274.85 / $274.85
| Facility | 26 | $274.85 | $274.85 | $274.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.46 / $1,280.82 / $2,794.48
| Professional | | $941.46 | $1,280.82 | $2,794.48 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $590.02 / $654.85 / $2,007.36
| Facility | 26 | $590.02 | $654.85 | $2,007.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.76 / $1,763.37 / $6,682.90
| Professional | | $837.76 | $1,763.37 | $6,682.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.05 / $2,346.92 / $3,723.71
| Professional | | $1,906.05 | $2,346.92 | $3,723.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.53 / $657.23 / $1,484.86
| Professional | | $197.53 | $657.23 | $1,484.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.70 / $2,363.40 / $3,840.52
| Professional | | $1,181.70 | $2,363.40 | $3,840.52 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,007.36 / $2,007.36 / $2,442.64
| Facility | 26 | $2,007.36 | $2,007.36 | $2,442.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.49 / $2,160.64 / $6,682.90
| Professional | | $1,366.49 | $2,160.64 | $6,682.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.46 / $1,763.37 / $3,737.65
| Professional | | $1,325.46 | $1,763.37 | $3,737.65 |