- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $107.15 / $107.15
| Facility | 26 | $66.07 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $426.58 / $776.25
| Professional | | $251.19 | $426.58 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $70.79 / $117.49 / $190.55
| Professional | 26 | $70.79 | $117.49 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $186.21 / $288.40 / $549.54
| Professional | TC | $186.21 | $288.40 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Professional | 26 | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $512.86 / $602.56
| Professional | | $186.21 | $512.86 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.50 / $134.90 / $173.78
| Professional | 26 | $95.50 | $134.90 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $134.90 / $371.54 / $436.52
| Professional | TC | $134.90 | $371.54 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $501.19 / $870.96
| Professional | | $281.84 | $501.19 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $93.33 / $190.55
| Professional | 26 | $54.95 | $93.33 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $208.93 / $371.54 / $707.95
| Professional | TC | $208.93 | $371.54 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $309.03 / $691.83
| Professional | | $213.80 | $309.03 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.12 / $72.44 / $91.20
| Professional | 26 | $50.12 | $72.44 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $154.88 / $223.87 / $660.69
| Professional | TC | $154.88 | $223.87 | $660.69 |