- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $81.28 / $81.28
| Facility | 26 | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $302.00 / $575.44
| Professional | | $204.17 | $302.00 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $51.29 / $81.28 / $147.91
| Professional | 26 | $51.29 | $81.28 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $158.49 / $218.78 / $426.58
| Professional | TC | $158.49 | $218.78 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.26 / $60.26 / $93.33
| Professional | 26 | $60.26 | $60.26 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $338.84 / $398.11
| Professional | | $123.03 | $338.84 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $131.83 / $154.88
| Professional | 26 | $67.61 | $131.83 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $75.86 / $208.93 / $245.47
| Professional | TC | $75.86 | $208.93 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $363.08 / $707.95
| Professional | | $239.88 | $363.08 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $85.11 / $169.82
| Professional | 26 | $54.95 | $85.11 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $186.21 / $281.84 / $575.44
| Professional | TC | $186.21 | $281.84 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $288.40 / $524.81
| Professional | | $208.93 | $288.40 | $524.81 |
- 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
- $154.88 / $223.87 / $446.68
| Professional | TC | $154.88 | $223.87 | $446.68 |