- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $116.29 / $116.29 / $116.29
| Facility | 26 | $116.29 | $116.29 | $116.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.45 / $584.98 / $2,287.71
| Professional | | $372.45 | $584.98 | $2,287.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.92 / $124.15 / $389.09
| Professional | 26 | $93.92 | $124.15 | $389.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $273.45 / $468.70 / $660.86
| Professional | TC | $273.45 | $468.70 | $660.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.57 / $603.28 / $1,020.92
| Professional | | $368.57 | $603.28 | $1,020.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $96.52 / $136.74 / $264.93
| Professional | 26 | $96.52 | $136.74 | $264.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $266.50 / $482.95 / $720.90
| Professional | TC | $266.50 | $482.95 | $720.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.03 / $235.74 / $362.92
| Professional | | $80.03 | $235.74 | $362.92 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $669.98 / $669.98 / $669.98
| Facility | 26 | $669.98 | $669.98 | $669.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.49 / $666.77 / $1,050.94
| Professional | | $580.49 | $666.77 | $1,050.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $152.19 / $177.60 / $236.64
| Professional | 26 | $152.19 | $177.60 | $236.64 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $428.30 / $495.19 / $824.70
| Professional | TC | $428.30 | $495.19 | $824.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.71 / $477.10 / $820.79
| Professional | | $349.71 | $477.10 | $820.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.70 / $106.29 / $186.01
| Professional | 26 | $89.70 | $106.29 | $186.01 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $254.61 / $387.57 / $713.79
| Professional | TC | $254.61 | $387.57 | $713.79 |