- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $401.68 / $401.68 / $401.68
| Facility | 26 | $401.68 | $401.68 | $401.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.58 / $1,477.71 / $2,292.90
| Professional | | $1,315.58 | $1,477.71 | $2,292.90 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $876.13 / $972.40 / $2,974.88
| Facility | 26 | $876.13 | $972.40 | $2,974.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.33 / $2,470.02 / $9,066.29
| Professional | | $1,162.33 | $2,470.02 | $9,066.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,609.89 / $3,180.24 / $5,045.85
| Professional | | $2,609.89 | $3,180.24 | $5,045.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.83 / $892.40 / $2,016.16
| Professional | | $292.83 | $892.40 | $2,016.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.86 / $3,213.72 / $5,164.97
| Professional | | $1,606.86 | $3,213.72 | $5,164.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.84 / $615.84 / $615.84
| Professional | | $615.84 | $615.84 | $615.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,974.88 / $2,974.88 / $3,621.28
| Facility | 26 | $2,974.88 | $2,974.88 | $3,621.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.70 / $2,989.11 / $9,066.29
| Professional | | $1,894.70 | $2,989.11 | $9,066.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.55 / $2,362.94 / $6,055.79
| Professional | | $1,767.55 | $2,362.94 | $6,055.79 |