- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $74.13 / $74.13 / $74.13
| Facility | 26 | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $346.74 / $562.34
| Professional | | $213.80 | $346.74 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $70.79 / $117.49 / $169.82
| Professional | 26 | $70.79 | $117.49 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $141.25 / $223.87 / $371.54
| Professional | TC | $141.25 | $223.87 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $891.25 / $891.25
| Professional | | $575.44 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $194.98 / $302.00 / $302.00
| Professional | 26 | $194.98 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $380.19 / $588.84 / $588.84
| Professional | TC | $380.19 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $537.03 / $870.96
| Professional | | $323.59 | $537.03 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $144.54 / $288.40
| Professional | 26 | $79.43 | $144.54 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $239.88 / $354.81 / $691.83
| Professional | TC | $239.88 | $354.81 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $446.68 / $1,096.48
| Professional | | $316.23 | $446.68 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $61.66 / $147.91 / $234.42
| Professional | 26 | $61.66 | $147.91 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $257.04 / $316.23 / $870.96
| Professional | TC | $257.04 | $316.23 | $870.96 |