- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $423.52 / $423.52 / $423.52
| Facility | 26 | $423.52 | $423.52 | $423.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.91 / $1,328.83 / $1,529.81
| Professional | | $1,251.91 | $1,328.83 | $1,529.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $354.37 / $423.52 / $685.34
| Professional | 26 | $354.37 | $423.52 | $685.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.20 / $1,669.21 / $1,953.15
| Professional | | $1,514.20 | $1,669.21 | $1,953.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $455.22 / $499.33 / $610.00
| Professional | 26 | $455.22 | $499.33 | $610.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.57 / $634.05 / $1,007.74
| Professional | | $227.57 | $634.05 | $1,007.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $5,276.22 / $5,276.22 / $5,276.22
| Facility | 26 | $5,276.22 | $5,276.22 | $5,276.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.11 / $2,409.25 / $3,032.77
| Professional | | $2,106.11 | $2,409.25 | $3,032.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $619.29 / $771.48 / $1,011.86
| Professional | 26 | $619.29 | $771.48 | $1,011.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.30 / $1,266.81 / $1,997.26
| Professional | | $1,092.30 | $1,266.81 | $1,997.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $320.10 / $392.00 / $585.29
| Professional | 26 | $320.10 | $392.00 | $585.29 |