- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | 26 | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $602.56 / $2,691.53
| Professional | | $371.54 | $602.56 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $229.09 / $676.08
| Professional | 26 | $114.82 | $229.09 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $257.04 / $416.87 / $870.96
| Professional | TC | $257.04 | $416.87 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $537.03 / $1,023.29
| Professional | | $398.11 | $537.03 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $123.03 / $154.88 / $251.19
| Professional | 26 | $123.03 | $154.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $251.19 / $323.59 / $426.58
| Professional | TC | $251.19 | $323.59 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $776.25 / $1,096.48
| Professional | | $338.84 | $776.25 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $102.33 / $229.09 / $275.42
| Professional | 26 | $102.33 | $229.09 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $239.88 / $524.81 / $812.83
| Professional | TC | $239.88 | $524.81 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $588.84 / $870.96
| Professional | | $426.58 | $588.84 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.20 / $147.91 / $239.88
| Professional | 26 | $112.20 | $147.91 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $295.12 / $426.58 / $602.56
| Professional | TC | $295.12 | $426.58 | $602.56 |