- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Facility | 26 | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $1,584.89
| Professional | | $794.33 | $1,122.02 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,479.11 / $1,737.80
| Professional | | $1,318.26 | $1,479.11 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $501.19 / $2,041.74
| Professional | | $32.36 | $501.19 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | 26 | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $2,754.23
| Professional | | $1,905.46 | $2,454.71 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,698.24 / $2,398.83
| Professional | | $933.25 | $1,698.24 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $1,096.48 / $1,548.82
| Professional | | $436.52 | $1,096.48 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,288.25 / $1,548.82
| Professional | | $851.14 | $1,288.25 | $1,548.82 |