- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $109.65 / $144.54
| Facility | 26 | $91.20 | $109.65 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $457.09 / $707.95
| Professional | | $338.84 | $457.09 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $109.65 / $194.98
| Professional | 26 | $85.11 | $109.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $257.04 / $338.84 / $512.86
| Professional | TC | $257.04 | $338.84 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $512.86 / $691.83
| Professional | | $446.68 | $512.86 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $117.49 / $151.36
| Professional | 26 | $100.00 | $117.49 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $338.84 / $389.05 / $549.54
| Professional | TC | $338.84 | $389.05 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $39.81 / $83.18 / $83.18
| Professional | 26 | $39.81 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $416.87 / $812.83
| Professional | | $239.88 | $416.87 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.26 / $93.33 / $177.83
| Professional | 26 | $60.26 | $93.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $177.83 / $323.59 / $630.96
| Professional | TC | $177.83 | $323.59 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $436.52 / $741.31
| Professional | | $302.00 | $436.52 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $72.44 / $91.20 / $138.04
| Professional | 26 | $72.44 | $91.20 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $223.87 / $323.59 / $537.03
| Professional | TC | $223.87 | $323.59 | $537.03 |