- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Facility | 26 | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $436.52 / $977.24
| Professional | | $281.84 | $436.52 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $131.83 / $354.81
| Professional | 26 | $87.10 | $131.83 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $213.80 / $323.59 / $741.31
| Professional | TC | $213.80 | $323.59 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $85.11 / $151.36
| Professional | 26 | $83.18 | $85.11 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $436.52 / $512.86
| Professional | | $309.03 | $436.52 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $72.44 / $104.71 / $123.03
| Professional | 26 | $72.44 | $104.71 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $234.42 / $331.13 / $389.05
| Professional | TC | $234.42 | $331.13 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $524.81 / $912.01
| Professional | | $371.54 | $524.81 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $104.71 / $128.82 / $218.78
| Professional | 26 | $104.71 | $128.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $281.84 / $398.11 / $707.95
| Professional | TC | $281.84 | $398.11 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $457.09 / $588.84
| Professional | | $338.84 | $457.09 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $109.65 / $147.91
| Professional | 26 | $79.43 | $109.65 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $245.47 / $346.74 / $436.52
| Professional | TC | $245.47 | $346.74 | $436.52 |