- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.71 / $144.54 / $257.04
| Facility | 26 | $104.71 | $144.54 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $398.11 / $851.14
| Professional | | $323.59 | $398.11 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $120.23 / $223.87
| Professional | 26 | $97.72 | $120.23 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $223.87 / $269.15 / $489.78
| Professional | TC | $223.87 | $269.15 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $426.58 / $831.76
| Professional | | $275.42 | $426.58 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $141.25 / $263.03
| Professional | 26 | $97.72 | $141.25 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $177.83 / $295.12 / $588.84
| Professional | TC | $177.83 | $295.12 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $26.92 / $151.36 / $436.52
| Facility | 26 | $26.92 | $151.36 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $524.81 / $1,202.26
| Professional | | $331.13 | $524.81 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.65 / $169.82 / $354.81
| Professional | 26 | $109.65 | $169.82 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $218.78 / $363.08 / $851.14
| Professional | TC | $218.78 | $363.08 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $407.38 / $776.25
| Professional | | $288.40 | $407.38 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.50 / $138.04 / $245.47
| Professional | 26 | $95.50 | $138.04 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $186.21 / $269.15 / $537.03
| Professional | TC | $186.21 | $269.15 | $537.03 |