- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.34 / $102.34 / $102.34
| Facility | 26 | $102.34 | $102.34 | $102.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.06 / $146.02 / $227.92
| Professional | | $106.06 | $146.02 | $227.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $35.29 / $45.58 / $84.70
| Professional | 26 | $35.29 | $45.58 | $84.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.90 / $175.57 / $211.71
| Professional | | $114.90 | $175.57 | $211.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $44.23 / $67.12 / $78.95
| Professional | 26 | $44.23 | $67.12 | $78.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.73 / $611.73 / $2,665.77
| Professional | | $611.73 | $611.73 | $2,665.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $335.03 / $335.03 / $405.23
| Professional | 26 | $335.03 | $335.03 | $405.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.19 / $204.04 / $261.73
| Professional | | $177.19 | $204.04 | $261.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $62.98 / $72.52 / $84.74
| Professional | 26 | $62.98 | $72.52 | $84.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $71.27 / $173.71
| Professional | | $32.34 | $71.27 | $173.71 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $3,403.52 / $3,403.52 / $3,403.52
| Facility | 26 | $3,403.52 | $3,403.52 | $3,403.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.47 / $228.79 / $261.73
| Professional | | $194.47 | $228.79 | $261.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $68.13 / $80.15 / $96.81
| Professional | 26 | $68.13 | $80.15 | $96.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.99 / $119.47 / $220.29
| Professional | | $108.99 | $119.47 | $220.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.55 / $45.98 / $82.28
| Professional | 26 | $42.55 | $45.98 | $82.28 |