- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Facility | 26 | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $389.05 / $549.54
| Professional | | $316.23 | $389.05 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $263.03 / $338.84 / $478.63
| Professional | TC | $263.03 | $338.84 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Professional | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $380.19 / $524.81
| Professional | | $56.23 | $380.19 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $380.19 / $588.84
| Professional | | $234.42 | $380.19 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $190.55 / $323.59 / $512.86
| Professional | TC | $190.55 | $323.59 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $128.82 / $346.74 / $346.74
| Facility | 26 | $128.82 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $407.38 / $2,691.53
| Professional | | $281.84 | $407.38 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $218.78 / $338.84 / $2,344.23
| Professional | TC | $218.78 | $338.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $363.08 / $602.56
| Professional | | $269.15 | $363.08 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $208.93 / $309.03 / $512.86
| Professional | TC | $208.93 | $309.03 | $512.86 |