- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $107.73 / $107.73 / $107.73
| Facility | 26 | $107.73 | $107.73 | $107.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.31 / $382.67 / $714.81
| Professional | | $316.31 | $382.67 | $714.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $262.79 / $328.81 / $620.22
| Professional | TC | $262.79 | $328.81 | $620.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.74 / $380.99 / $476.24
| Professional | | $285.74 | $380.99 | $476.24 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $247.78 / $330.38 / $412.97
| Professional | TC | $247.78 | $330.38 | $412.97 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $63.88 / $63.88 / $63.88
| Facility | 26 | $63.88 | $63.88 | $63.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.94 / $439.23 / $837.72
| Professional | | $253.94 | $439.23 | $837.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $196.27 / $376.27 / $720.73
| Professional | TC | $196.27 | $376.27 | $720.73 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $128.97 / $347.00 / $347.00
| Facility | 26 | $128.97 | $347.00 | $347.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.40 / $384.42 / $2,673.66
| Professional | | $229.40 | $384.42 | $2,673.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $177.97 / $326.39 / $2,317.40
| Professional | TC | $177.97 | $326.39 | $2,317.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.20 / $365.97 / $733.93
| Professional | | $223.20 | $365.97 | $733.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $171.85 / $311.51 / $624.73
| Professional | TC | $171.85 | $311.51 | $624.73 |