- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $379.90 / $417.88 / $417.88
| Facility | 26 | $379.90 | $417.88 | $417.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.07 / $1,254.93 / $1,386.19
| Professional | | $1,184.07 | $1,254.93 | $1,386.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $343.99 / $392.05 / $808.44
| Professional | 26 | $343.99 | $392.05 | $808.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.21 / $1,595.32 / $2,421.44
| Professional | | $702.21 | $1,595.32 | $2,421.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $417.96 / $417.96 / $417.96
| Facility | 26 | $417.96 | $417.96 | $417.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.82 / $1,828.06 / $5,544.16
| Professional | | $1,153.82 | $1,828.06 | $5,544.16 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $350.00 / $578.17 / $1,700.98
| Professional | 26 | $350.00 | $578.17 | $1,700.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.85 / $1,496.04 / $2,602.67
| Professional | | $950.85 | $1,496.04 | $2,602.67 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $300.83 / $449.10 / $862.89
| Professional | 26 | $300.83 | $449.10 | $862.89 |