- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $118.80 / $118.80 / $229.48
| Facility | 26 | $118.80 | $118.80 | $229.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.65 / $333.14 / $612.20
| Professional | | $242.65 | $333.14 | $612.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $94.31 / $105.12 / $229.48
| Professional | 26 | $94.31 | $105.12 | $229.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $151.85 / $210.91 / $382.73
| Professional | TC | $151.85 | $210.91 | $382.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.83 / $429.83 / $429.83
| Professional | | $429.83 | $429.83 | $429.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.23 / $419.25 / $894.57
| Professional | | $254.23 | $419.25 | $894.57 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.15 / $153.62 / $321.77
| Professional | 26 | $100.15 | $153.62 | $321.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $156.55 / $248.56 / $671.89
| Professional | TC | $156.55 | $248.56 | $671.89 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $232.57 / $232.57 / $232.57
| Facility | 26 | $232.57 | $232.57 | $232.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.96 / $353.03 / $2,013.87
| Professional | | $244.96 | $353.03 | $2,013.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.28 / $138.29 / $716.57
| Professional | 26 | $109.28 | $138.29 | $716.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $130.31 / $210.01 / $1,590.04
| Professional | TC | $130.31 | $210.01 | $1,590.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.76 / $322.75 / $625.40
| Professional | | $230.76 | $322.75 | $625.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $106.94 / $133.05 / $252.61
| Professional | 26 | $106.94 | $133.05 | $252.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $116.39 / $196.48 / $366.67
| Professional | TC | $116.39 | $196.48 | $366.67 |