- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | 26 | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $371.54 / $1,023.29
| Professional | | $239.88 | $371.54 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $104.71 / $213.80
| Professional | 26 | $57.54 | $104.71 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $158.49 / $281.84 / $537.03
| Professional | TC | $158.49 | $281.84 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $338.84 / $562.34
| Professional | | $257.04 | $338.84 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.26 / $77.62 / $125.89
| Professional | 26 | $60.26 | $77.62 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $177.83 / $213.80 / $295.12
| Professional | TC | $177.83 | $213.80 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $467.74 / $707.95
| Professional | | $204.17 | $467.74 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $51.29 / $114.82 / $131.83
| Professional | 26 | $51.29 | $114.82 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $151.36 / $354.81 / $537.03
| Professional | TC | $151.36 | $354.81 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $316.23 / $524.81
| Professional | | $251.19 | $316.23 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $72.44 / $117.49
| Professional | 26 | $54.95 | $72.44 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $186.21 / $239.88 / $407.38
| Professional | TC | $186.21 | $239.88 | $407.38 |