- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $95.44 / $95.44 / $95.44
| Facility | 26 | $95.44 | $95.44 | $95.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.90 / $396.06 / $396.32
| Professional | | $370.90 | $396.06 | $396.32 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $84.47 / $90.76 / $95.44
| Professional | 26 | $84.47 | $90.76 | $95.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $283.39 / $300.88 / $311.58
| Professional | TC | $283.39 | $300.88 | $311.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.75 / $599.69 / $1,582.38
| Professional | | $508.75 | $599.69 | $1,582.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.52 / $531.25 / $1,582.38
| Professional | | $322.52 | $531.25 | $1,582.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $65.75 / $121.06 / $306.32
| Professional | 26 | $65.75 | $121.06 | $306.32 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $226.63 / $418.01 / $732.94
| Professional | TC | $226.63 | $418.01 | $732.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.52 / $595.99 / $980.94
| Professional | | $322.52 | $595.99 | $980.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.90 / $121.06 / $198.12
| Professional | 26 | $109.90 | $121.06 | $198.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $226.63 / $459.01 / $732.94
| Professional | TC | $226.63 | $459.01 | $732.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.03 / $537.39 / $1,700.00
| Professional | | $366.03 | $537.39 | $1,700.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $118.64 / $124.43 / $361.74
| Professional | 26 | $118.64 | $124.43 | $361.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $247.39 / $460.35 / $1,338.26
| Professional | TC | $247.39 | $460.35 | $1,338.26 |