- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Facility | 26 | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $323.59 / $676.08
| Professional | | $218.78 | $323.59 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $120.23 / $239.88
| Professional | 26 | $54.95 | $120.23 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $151.36 / $223.87 / $416.87
| Professional | TC | $151.36 | $223.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $89.13 / $120.23
| Professional | 26 | $63.10 | $89.13 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $436.52 / $512.86
| Professional | | $158.49 | $436.52 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $131.83 / $169.82
| Professional | 26 | $91.20 | $131.83 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $112.20 / $309.03 / $363.08
| Professional | TC | $112.20 | $309.03 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $446.68 / $912.01
| Professional | | $288.40 | $446.68 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $109.65 / $223.87
| Professional | 26 | $83.18 | $109.65 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $204.17 / $323.59 / $676.08
| Professional | TC | $204.17 | $323.59 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $354.81 / $691.83
| Professional | | $245.47 | $354.81 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $89.13 / $131.83
| Professional | 26 | $67.61 | $89.13 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $173.78 / $251.19 / $562.34
| Professional | TC | $173.78 | $251.19 | $562.34 |