- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | 26 | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $2,187.76
| Professional | | $1,122.02 | $1,513.56 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,041.74 / $2,398.83
| Professional | | $1,862.09 | $2,041.74 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $660.69 / $2,818.38
| Professional | | $32.36 | $660.69 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | 26 | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $3,801.89
| Professional | | $2,570.40 | $3,467.37 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,344.23 / $3,311.31
| Professional | | $1,258.93 | $2,344.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,445.44 / $2,238.72
| Professional | | $562.34 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,137.96
| Professional | | $1,202.26 | $1,778.28 | $2,137.96 |