- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $520.63 / $520.63 / $520.63
| Facility | 26 | $520.63 | $520.63 | $520.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.93 / $1,629.64 / $1,873.84
| Professional | | $1,590.93 | $1,629.64 | $1,873.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.68 / $2,044.30 / $2,403.64
| Professional | | $1,857.68 | $2,044.30 | $2,403.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.88 / $778.15 / $1,300.83
| Professional | | $302.88 | $778.15 | $1,300.83 |
- 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
- $2,577.73 / $2,958.62 / $3,721.08
| Professional | | $2,577.73 | $2,958.62 | $3,721.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.00 / $1,562.40 / $2,473.92
| Professional | | $1,353.00 | $1,562.40 | $2,473.92 |