- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $200.98 / $200.98 / $200.98
| Facility | 26 | $200.98 | $200.98 | $200.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.08 / $675.62 / $709.40
| Professional | | $324.08 | $675.62 | $709.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $98.04 / $200.98 / $211.02
| Professional | 26 | $98.04 | $200.98 | $211.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $226.04 / $474.64 / $498.37
| Professional | TC | $226.04 | $474.64 | $498.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.07 / $346.67 / $409.07
| Professional | | $253.07 | $346.67 | $409.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $77.30 / $105.89 / $124.95
| Professional | 26 | $77.30 | $105.89 | $124.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $175.77 / $240.78 / $284.12
| Professional | TC | $175.77 | $240.78 | $284.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.95 / $379.39 / $914.19
| Professional | | $313.95 | $379.39 | $914.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.96 / $138.76 / $333.01
| Professional | 26 | $97.96 | $138.76 | $333.01 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $195.24 / $240.78 / $581.16
| Professional | TC | $195.24 | $240.78 | $581.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.29 / $323.93 / $525.79
| Professional | | $264.29 | $323.93 | $525.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.37 / $116.72 / $171.88
| Professional | 26 | $83.37 | $116.72 | $171.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $174.47 / $218.04 / $353.92
| Professional | TC | $174.47 | $218.04 | $353.92 |