- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $67.61 / $95.50
| Facility | 26 | $67.61 | $67.61 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $354.81 / $616.60
| Professional | | $295.12 | $354.81 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $562.34 / $1,905.46
| Professional | | $346.74 | $562.34 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.23 / $138.04 / $223.87
| Facility | 26 | $120.23 | $138.04 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $776.25 / $1,445.44
| Professional | | $380.19 | $776.25 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $776.25 / $1,071.52
| Professional | | $645.65 | $776.25 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Facility | 26 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $741.31 / $2,398.83
| Professional | | $407.38 | $741.31 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $70.79
| Professional | | $32.36 | $33.11 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $812.83 / $1,230.27
| Professional | | $457.09 | $812.83 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.71 / $288.40 / $288.40
| Facility | 26 | $104.71 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,905.46 / $2,398.83
| Professional | | $489.78 | $1,905.46 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,348.96 / $2,398.83
| Professional | | $891.25 | $1,348.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $1,380.38
| Professional | | $398.11 | $588.84 | $1,380.38 |