- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.24 / $58.24 / $59.35
| Facility | 26 | $58.24 | $58.24 | $59.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.07 / $210.80 / $292.80
| Professional | | $151.07 | $210.80 | $292.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $55.15 / $68.13 / $141.35
| Professional | 26 | $55.15 | $68.13 | $141.35 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $93.97 / $135.41 / $231.46
| Professional | TC | $93.97 | $135.41 | $231.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.00 / $690.00 / $690.00
| Professional | | $420.00 | $690.00 | $690.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $155.00 / $255.00 / $255.00
| Professional | 26 | $155.00 | $255.00 | $255.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $265.00 / $435.00 / $435.00
| Professional | TC | $265.00 | $435.00 | $435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.19 / $352.31 / $711.17
| Professional | | $259.19 | $352.31 | $711.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.37 / $104.95 / $183.52
| Professional | 26 | $69.37 | $104.95 | $183.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $163.76 / $244.08 / $483.60
| Professional | TC | $163.76 | $244.08 | $483.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.54 / $375.21 / $916.30
| Professional | | $261.54 | $375.21 | $916.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $53.24 / $114.71 / $196.90
| Professional | 26 | $53.24 | $114.71 | $196.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $204.25 / $266.77 / $816.18
| Professional | TC | $204.25 | $266.77 | $816.18 |