- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $257.55 / $257.55 / $257.55
| Facility | 26 | $257.55 | $257.55 | $257.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.00 / $522.50 / $1,492.05
| Professional | | $475.00 | $522.50 | $1,492.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $140.00 / $154.00 / $504.92
| Professional | 26 | $140.00 | $154.00 | $504.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $335.00 / $368.50 / $987.13
| Professional | TC | $335.00 | $368.50 | $987.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.49 / $1,011.97 / $1,055.00
| Professional | | $409.49 | $1,011.97 | $1,055.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $123.13 / $282.08 / $307.50
| Professional | 26 | $123.13 | $282.08 | $307.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $286.36 / $717.50 / $738.50
| Professional | TC | $286.36 | $717.50 | $738.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.68 / $792.81 / $1,731.95
| Professional | | $660.68 | $792.81 | $1,731.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $196.50 / $241.09 / $593.73
| Professional | 26 | $196.50 | $241.09 | $593.73 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $430.49 / $557.01 / $1,138.17
| Professional | TC | $430.49 | $557.01 | $1,138.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.25 / $1,196.00 / $1,970.60
| Professional | | $1,021.25 | $1,196.00 | $1,970.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $303.75 / $328.05 / $555.75
| Professional | 26 | $303.75 | $328.05 | $555.75 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $717.50 / $900.20 / $1,476.00
| Professional | TC | $717.50 | $900.20 | $1,476.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.14 / $1,035.00 / $1,953.39
| Professional | | $384.14 | $1,035.00 | $1,953.39 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $265.26 / $369.00 / $549.80
| Professional | 26 | $265.26 | $369.00 | $549.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $717.50 / $942.00 / $1,476.00
| Professional | TC | $717.50 | $942.00 | $1,476.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $749.36 / $896.71 / $1,554.06
| Professional | | $749.36 | $896.71 | $1,554.06 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $118.23 / $364.86 / $516.89
| Professional | 26 | $118.23 | $364.86 | $516.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $506.12 / $759.18 / $1,075.50
| Professional | TC | $506.12 | $759.18 | $1,075.50 |