- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.57 / $117.49 / $117.49
| Facility | 26 | $64.57 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $446.68 / $1,047.13
| Professional | | $302.00 | $446.68 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $64.57 / $117.49
| Professional | 26 | $34.67 | $64.57 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $269.15 / $407.38 / $933.25
| Professional | TC | $269.15 | $407.38 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $407.38 / $616.60
| Professional | | $288.40 | $407.38 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.11 / $35.48 / $66.07
| Professional | 26 | $33.11 | $35.48 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $251.19 / $269.15 / $363.08
| Professional | TC | $251.19 | $269.15 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $616.60 / $741.31
| Professional | | $234.42 | $616.60 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $24.55 / $69.18 / $83.18
| Professional | 26 | $24.55 | $69.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $208.93 / $549.54 / $676.08
| Professional | TC | $208.93 | $549.54 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $467.74 / $870.96
| Professional | | $199.53 | $467.74 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.99 / $52.48 / $79.43
| Professional | 26 | $23.99 | $52.48 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $177.83 / $416.87 / $776.25
| Professional | TC | $177.83 | $416.87 | $776.25 |