- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $542.40 / $542.40 / $542.40
| Facility | 26 | $542.40 | $542.40 | $542.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.31 / $565.34 / $600.00
| Professional | | $368.31 | $565.34 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.58 / $140.00 / $180.00
| Professional | 26 | $93.58 | $140.00 | $180.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $277.77 / $420.00 / $446.53
| Professional | TC | $277.77 | $420.00 | $446.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.68 / $491.39 / $929.04
| Professional | | $417.68 | $491.39 | $929.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $84.63 / $120.90 / $168.49
| Professional | 26 | $84.63 | $120.90 | $168.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $259.33 / $370.49 / $421.09
| Professional | TC | $259.33 | $370.49 | $421.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.82 / $709.13 / $805.37
| Professional | | $338.82 | $709.13 | $805.37 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $78.39 / $170.79 / $181.50
| Professional | 26 | $78.39 | $170.79 | $181.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $258.14 / $538.34 / $602.25
| Professional | TC | $258.14 | $538.34 | $602.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.92 / $547.73 / $719.50
| Professional | | $406.92 | $547.73 | $719.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.67 / $106.84 / $179.52
| Professional | 26 | $81.67 | $106.84 | $179.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $297.38 / $381.04 / $590.73
| Professional | TC | $297.38 | $381.04 | $590.73 |