- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Facility | 26 | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $407.38 / $954.99
| Professional | | $354.81 | $407.38 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $104.71 / $128.82 / $269.15
| Professional | 26 | $104.71 | $128.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $245.47 / $295.12 / $691.83
| Professional | TC | $245.47 | $295.12 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $389.05 / $660.69
| Professional | | $323.59 | $389.05 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.50 / $138.04 / $190.55
| Professional | 26 | $95.50 | $138.04 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $204.17 / $275.42 / $478.63
| Professional | TC | $204.17 | $275.42 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $363.08 / $549.54
| Professional | | $288.40 | $363.08 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $123.03 / $190.55
| Professional | 26 | $100.00 | $123.03 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $186.21 / $239.88 / $354.81
| Professional | TC | $186.21 | $239.88 | $354.81 |