- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Facility | 26 | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $478.63 / $1,698.24
| Professional | | $295.12 | $478.63 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.13 / $141.25 / $229.09
| Professional | 26 | $74.13 | $141.25 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $204.17 / $354.81 / $724.44
| Professional | TC | $204.17 | $354.81 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $389.05 / $741.31
| Professional | | $288.40 | $389.05 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.18 / $89.13 / $144.54
| Professional | 26 | $69.18 | $89.13 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $199.53 / $281.84 / $346.74
| Professional | TC | $199.53 | $281.84 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $562.34 / $794.33
| Professional | | $251.19 | $562.34 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $134.90 / $154.88
| Professional | 26 | $58.88 | $134.90 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $199.53 / $416.87 / $602.56
| Professional | TC | $199.53 | $416.87 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $446.68 / $630.96
| Professional | | $316.23 | $446.68 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $64.57 / $85.11 / $131.83
| Professional | 26 | $64.57 | $85.11 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $234.42 / $338.84 / $478.63
| Professional | TC | $234.42 | $338.84 | $478.63 |