- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $444.25 / $444.25 / $444.25
| Facility | 26 | $444.25 | $444.25 | $444.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.86 / $512.22 / $669.75
| Professional | | $315.86 | $512.22 | $669.75 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.38 / $140.00 / $381.44
| Professional | 26 | $89.38 | $140.00 | $381.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $242.11 / $415.86 / $470.23
| Professional | TC | $242.11 | $415.86 | $470.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.58 / $463.04 / $945.07
| Professional | | $393.58 | $463.04 | $945.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.16 / $98.80 / $136.25
| Professional | 26 | $69.16 | $98.80 | $136.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $254.97 / $364.24 / $364.24
| Professional | TC | $254.97 | $364.24 | $364.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.89 / $718.71 / $809.94
| Professional | | $339.89 | $718.71 | $809.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $63.48 / $135.00 / $148.63
| Professional | 26 | $63.48 | $135.00 | $148.63 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $272.54 / $579.28 / $661.29
| Professional | TC | $272.54 | $579.28 | $661.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.35 / $512.41 / $761.94
| Professional | | $342.35 | $512.41 | $761.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $64.84 / $86.21 / $146.68
| Professional | 26 | $64.84 | $86.21 | $146.68 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $326.51 / $418.37 / $860.85
| Professional | TC | $326.51 | $418.37 | $860.85 |