- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $46.77 / $89.13 / $208.93
| Facility | 26 | $46.77 | $89.13 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $125.89 / $446.68
| Professional | | $102.33 | $125.89 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $13.18 / $61.66 / $87.10
| Facility | 26 | $13.18 | $61.66 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $295.12 / $741.31
| Professional | | $125.89 | $295.12 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | 26 | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $363.08 / $1,000.00
| Professional | | $218.78 | $363.08 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $223.87 / $537.03
| Professional | | $131.83 | $223.87 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | 26 | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |