- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $71.65 / $71.65 / $71.65
| Facility | 26 | $71.65 | $71.65 | $71.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.25 / $522.50 / $709.39
| Professional | | $389.25 | $522.50 | $709.39 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $62.87 / $140.00 / $189.00
| Professional | 26 | $62.87 | $140.00 | $189.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.39 / $983.59 / $1,229.48
| Professional | | $804.39 | $983.59 | $1,229.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $131.94 / $161.35 / $201.68
| Professional | 26 | $131.94 | $161.35 | $201.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.04 / $847.08 / $2,775.50
| Professional | | $484.04 | $847.08 | $2,775.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $88.01 / $132.01 / $439.61
| Professional | 26 | $88.01 | $132.01 | $439.61 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $239.90 / $239.90 / $239.90
| Facility | 26 | $239.90 | $239.90 | $239.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.68 / $897.00 / $1,307.88
| Professional | | $783.68 | $897.00 | $1,307.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.60 / $685.73 / $806.68
| Professional | | $541.60 | $685.73 | $806.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.71 / $121.12 / $135.85
| Professional | 26 | $90.71 | $121.12 | $135.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.70 / $871.26 / $871.26
| Professional | | $509.70 | $871.26 | $871.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.48 / $132.01 / $148.26
| Professional | 26 | $83.48 | $132.01 | $148.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.30 / $1,092.09 / $1,092.09
| Professional | | $928.30 | $1,092.09 | $1,092.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $156.30 / $183.90 / $183.90
| Professional | 26 | $156.30 | $183.90 | $183.90 |