- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $932.71 / $932.71 / $932.71
| Facility | 26 | $932.71 | $932.71 | $932.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.11 / $268.36 / $327.94
| Professional | | $193.11 | $268.36 | $327.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $102.20 / $137.41 / $179.12
| Professional | 26 | $102.20 | $137.41 | $179.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $90.91 / $126.03 / $151.13
| Professional | TC | $90.91 | $126.03 | $151.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.47 / $350.46 / $588.45
| Professional | | $308.47 | $350.46 | $588.45 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $128.65 / $183.79 / $304.22
| Professional | 26 | $128.65 | $183.79 | $304.22 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $116.67 / $166.67 / $183.05
| Professional | TC | $116.67 | $166.67 | $183.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.06 / $591.59 / $806.86
| Professional | | $365.06 | $591.59 | $806.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $191.45 / $312.08 / $418.56
| Professional | 26 | $191.45 | $312.08 | $418.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $173.61 / $279.50 / $388.30
| Professional | TC | $173.61 | $279.50 | $388.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.69 / $368.98 / $491.97
| Professional | | $258.69 | $368.98 | $491.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $133.36 / $213.01 / $259.54
| Professional | 26 | $133.36 | $213.01 | $259.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $101.69 / $174.32 / $325.12
| Professional | TC | $101.69 | $174.32 | $325.12 |