- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $540.33 / $540.33 / $540.33
| Facility | 26 | $540.33 | $540.33 | $540.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.17 / $572.67 / $600.00
| Professional | | $372.17 | $572.67 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.19 / $140.00 / $180.00
| Professional | 26 | $90.19 | $140.00 | $180.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $281.98 / $420.00 / $454.32
| Professional | TC | $281.98 | $420.00 | $454.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.51 / $497.07 / $939.12
| Professional | | $422.51 | $497.07 | $939.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $84.51 / $120.73 / $167.84
| Professional | 26 | $84.51 | $120.73 | $167.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $263.43 / $376.33 / $425.82
| Professional | TC | $263.43 | $376.33 | $425.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.75 / $715.37 / $804.87
| Professional | | $342.75 | $715.37 | $804.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $78.09 / $170.11 / $180.79
| Professional | 26 | $78.09 | $170.11 | $180.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $263.23 / $545.26 / $610.27
| Professional | TC | $263.23 | $545.26 | $610.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.74 / $515.95 / $766.87
| Professional | | $393.74 | $515.95 | $766.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.69 / $105.35 / $161.07
| Professional | 26 | $80.69 | $105.35 | $161.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $301.32 / $402.74 / $598.30
| Professional | TC | $301.32 | $402.74 | $598.30 |