- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.33 / $102.33 / $102.33
| Facility | 26 | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $457.09 / $870.96
| Professional | | $346.74 | $457.09 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $128.82 / $263.03
| Professional | 26 | $83.18 | $128.82 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $257.04 / $338.84 / $660.69
| Professional | TC | $257.04 | $338.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | 26 | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $457.09 / $707.95
| Professional | | $323.59 | $457.09 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $158.49 / $275.42
| Professional | 26 | $83.18 | $158.49 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $234.42 / $269.15 / $512.86
| Professional | TC | $234.42 | $269.15 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $977.24
| Professional | | $389.05 | $562.34 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $114.82 / $194.98
| Professional | 26 | $83.18 | $114.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $295.12 / $426.58 / $758.58
| Professional | TC | $295.12 | $426.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $870.96
| Professional | | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $165.96 / $165.96 / $165.96
| Professional | 26 | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $512.86 / $891.25
| Professional | | $363.08 | $512.86 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $100.00 / $173.78
| Professional | 26 | $81.28 | $100.00 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $275.42 / $416.87 / $741.31
| Professional | TC | $275.42 | $416.87 | $741.31 |