- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.20 / $60.20 / $60.20
| Facility | 26 | $60.20 | $60.20 | $60.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.98 / $340.28 / $383.84
| Professional | | $318.98 | $340.28 | $383.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $263.79 / $280.08 / $327.94
| Professional | TC | $263.79 | $280.08 | $327.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.31 / $512.84 / $1,535.57
| Professional | | $425.31 | $512.84 | $1,535.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.11 / $507.87 / $1,535.57
| Professional | | $262.11 | $507.87 | $1,535.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $204.64 / $428.98 / $763.75
| Professional | TC | $204.64 | $428.98 | $763.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.51 / $506.37 / $895.14
| Professional | | $257.51 | $506.37 | $895.14 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $204.64 / $425.74 / $700.41
| Professional | TC | $204.64 | $425.74 | $700.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.61 / $380.22 / $1,634.43
| Professional | | $304.61 | $380.22 | $1,634.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $229.92 / $479.71 / $1,394.55
| Professional | TC | $229.92 | $479.71 | $1,394.55 |