- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.96 / $90.81 / $90.81
| Facility | 26 | $60.96 | $90.81 | $90.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.47 / $166.33 / $194.27
| Professional | | $101.47 | $166.33 | $194.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $49.65 / $60.36 / $90.81
| Professional | 26 | $49.65 | $60.36 | $90.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $47.80 / $75.52 / $144.61
| Professional | TC | $47.80 | $75.52 | $144.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.20 / $274.25 / $323.62
| Professional | | $200.20 | $274.25 | $323.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.56 / $103.50 / $122.13
| Professional | 26 | $75.56 | $103.50 | $122.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $124.65 / $170.75 / $201.49
| Professional | TC | $124.65 | $170.75 | $201.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $63.73 / $63.73 / $64.29
| Facility | 26 | $63.73 | $63.73 | $64.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.57 / $173.00 / $434.53
| Professional | | $98.57 | $173.00 | $434.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.60 / $69.58 / $161.41
| Professional | 26 | $52.60 | $69.58 | $161.41 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $45.73 / $110.33 / $336.45
| Professional | TC | $45.73 | $110.33 | $336.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.10 / $134.40 / $464.36
| Professional | | $106.10 | $134.40 | $464.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $47.40 / $68.23 / $86.18
| Professional | 26 | $47.40 | $68.23 | $86.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $53.63 / $69.65 / $395.74
| Professional | TC | $53.63 | $69.65 | $395.74 |