- 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
- $199.53 / $426.58 / $1,380.38
| Professional | | $199.53 | $426.58 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $91.20 / $269.15
| Professional | 26 | $66.07 | $91.20 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $75.86 / $147.91 / $602.56
| Professional | 52 | $75.86 | $147.91 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $147.91 / $257.04 / $616.60
| Professional | TC | $147.91 | $257.04 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $288.40 / $537.03
| Professional | | $218.78 | $288.40 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.18 / $91.20 / $144.54
| Professional | 26 | $69.18 | $91.20 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $131.83 / $177.83 / $223.87
| Professional | TC | $131.83 | $177.83 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $416.87 / $891.25
| Professional | | $190.55 | $416.87 | $891.25 |
- 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
- $134.90 / $281.84 / $741.31
| Professional | TC | $134.90 | $281.84 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $354.81 / $588.84
| Professional | | $229.09 | $354.81 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $64.57 / $85.11 / $134.90
| Professional | 26 | $64.57 | $85.11 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $151.36 / $213.80 / $436.52
| Professional | TC | $151.36 | $213.80 | $436.52 |