- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $83.18 / $83.18
| Facility | 26 | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $263.03 / $562.34
| Professional | | $169.82 | $263.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $51.29 / $85.11 / $177.83
| Professional | 26 | $51.29 | $85.11 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $114.82 / $173.78 / $331.13
| Professional | TC | $114.82 | $173.78 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.66 / $70.79 / $91.20
| Professional | 26 | $42.66 | $70.79 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $295.12 / $346.74
| Professional | | $107.15 | $295.12 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $117.49 / $151.36
| Professional | 26 | $83.18 | $117.49 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $64.57 / $177.83 / $208.93
| Professional | TC | $64.57 | $177.83 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $302.00 / $537.03
| Professional | | $169.82 | $302.00 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $83.18 / $169.82
| Professional | 26 | $56.23 | $83.18 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $125.89 / $218.78 / $416.87
| Professional | TC | $125.89 | $218.78 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $218.78 / $436.52
| Professional | | $154.88 | $218.78 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $45.71 / $60.26 / $89.13
| Professional | 26 | $45.71 | $60.26 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $102.33 / $147.91 / $354.81
| Professional | TC | $102.33 | $147.91 | $354.81 |