- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $525.44 / $525.44 / $525.44
| Facility | 26 | $525.44 | $525.44 | $525.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.47 / $600.00 / $648.51
| Professional | | $335.47 | $600.00 | $648.51 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.45 / $124.36 / $180.00
| Professional | 26 | $87.45 | $124.36 | $180.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $248.02 / $420.00 / $533.85
| Professional | TC | $248.02 | $420.00 | $533.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.64 / $445.73 / $1,045.23
| Professional | | $386.64 | $445.73 | $1,045.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.59 / $116.57 / $161.97
| Professional | 26 | $81.59 | $116.57 | $161.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $230.41 / $329.16 / $354.87
| Professional | TC | $230.41 | $329.16 | $354.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.10 / $642.24 / $881.96
| Professional | | $343.10 | $642.24 | $881.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.66 / $164.64 / $175.81
| Professional | 26 | $75.66 | $164.64 | $175.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $279.33 / $477.60 / $683.95
| Professional | TC | $279.33 | $477.60 | $683.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.35 / $512.83 / $723.24
| Professional | | $354.35 | $512.83 | $723.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.47 / $99.60 / $173.18
| Professional | 26 | $75.47 | $99.60 | $173.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $228.23 / $394.75 / $563.41
| Professional | TC | $228.23 | $394.75 | $563.41 |