- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $623.98 / $623.98 / $623.98
| Facility | 26 | $623.98 | $623.98 | $623.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.97 / $1,251.91 / $2,533.84
| Professional | | $1,089.97 | $1,251.91 | $2,533.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $316.02 / $387.38 / $1,463.00
| Professional | 26 | $316.02 | $387.38 | $1,463.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $276.64 / $276.64 / $276.64
| Professional | 26 | $276.64 | $276.64 | $276.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.72 / $1,070.30 / $1,337.87
| Professional | | $802.72 | $1,070.30 | $1,337.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $241.87 / $322.49 / $403.11
| Professional | 26 | $241.87 | $322.49 | $403.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.90 / $1,360.38 / $2,021.87
| Professional | | $1,162.90 | $1,360.38 | $2,021.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $339.44 / $411.87 / $596.67
| Professional | 26 | $339.44 | $411.87 | $596.67 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,401.92 / $2,401.92 / $3,007.60
| Facility | 26 | $2,401.92 | $2,401.92 | $3,007.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.30 / $1,337.31 / $2,683.68
| Professional | | $1,092.30 | $1,337.31 | $2,683.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $320.10 / $402.80 / $829.61
| Professional | 26 | $320.10 | $402.80 | $829.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.30 / $1,268.73 / $1,982.99
| Professional | | $1,092.30 | $1,268.73 | $1,982.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $320.10 / $378.30 / $604.21
| Professional | 26 | $320.10 | $378.30 | $604.21 |