- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Facility | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $323.59 / $602.56
| Professional | | $251.19 | $323.59 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.86 / $102.33 / $275.42
| Professional | 26 | $75.86 | $102.33 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $389.05 / $1,000.00
| Professional | | $263.03 | $389.05 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $120.23 / $275.42
| Professional | 26 | $83.18 | $120.23 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $549.54 / $870.96
| Professional | | $331.13 | $549.54 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $117.49 / $208.93
| Professional | 26 | $85.11 | $117.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $457.09 / $851.14
| Professional | | $354.81 | $457.09 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $125.89 / $234.42
| Professional | 26 | $100.00 | $125.89 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Facility | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $398.11 / $851.14
| Professional | | $275.42 | $398.11 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $117.49 / $269.15
| Professional | 26 | $83.18 | $117.49 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $467.74 / $891.25
| Professional | | $309.03 | $467.74 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $128.82 / $234.42
| Professional | 26 | $89.13 | $128.82 | $234.42 |