- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $2,238.72
| Professional | | $1,174.90 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $323.59 / $426.58 / $1,479.11
| Professional | 26 | $323.59 | $426.58 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,737.80 / $1,737.80
| Professional | | $512.86 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $512.86 / $512.86 / $602.56
| Facility | 26 | $512.86 | $512.86 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $2,691.53
| Professional | | $1,258.93 | $1,737.80 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $389.05 / $512.86 / $776.25
| Professional | 26 | $389.05 | $512.86 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,949.84 / $2,344.23
| Professional | | $1,905.46 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $512.86 / $512.86 / $602.56
| Facility | 26 | $512.86 | $512.86 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $2,454.71
| Professional | | $1,202.26 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $346.74 / $478.63 / $741.31
| Professional | 26 | $346.74 | $478.63 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,949.84 / $2,238.72
| Professional | | $1,737.80 | $1,949.84 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $501.19 / $575.44 / $676.08
| Professional | 26 | $501.19 | $575.44 | $676.08 |