- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.60 / $57.60 / $58.68
| Facility | 26 | $57.60 | $57.60 | $58.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.02 / $299.89 / $385.44
| Professional | | $216.02 | $299.89 | $385.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.86 / $61.04 / $81.42
| Professional | 26 | $54.86 | $61.04 | $81.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $159.25 / $218.47 / $324.39
| Professional | TC | $159.25 | $218.47 | $324.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.00 / $1,027.00 / $1,027.00
| Professional | | $625.00 | $1,027.00 | $1,027.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $154.00 / $253.00 / $253.00
| Professional | 26 | $154.00 | $253.00 | $253.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $471.00 / $774.00 / $774.00
| Professional | TC | $471.00 | $774.00 | $774.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.98 / $451.47 / $763.39
| Professional | | $300.98 | $451.47 | $763.39 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $68.97 / $104.34 / $182.52
| Professional | 26 | $68.97 | $104.34 | $182.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $216.24 / $324.36 / $595.99
| Professional | TC | $216.24 | $324.36 | $595.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.05 / $452.12 / $984.49
| Professional | | $285.05 | $452.12 | $984.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.01 / $114.72 / $205.71
| Professional | 26 | $54.01 | $114.72 | $205.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $231.04 / $358.71 / $788.70
| Professional | TC | $231.04 | $358.71 | $788.70 |