- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $241.27 / $241.27 / $335.68
| Facility | 26 | $241.27 | $241.27 | $335.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.82 / $98.77 / $437.57
| Professional | | $48.82 | $98.77 | $437.57 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $29.17 / $41.95 / $208.54
| Professional | 26 | $29.17 | $41.95 | $208.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $19.66 / $56.23 / $119.70
| Professional | TC | $19.66 | $56.23 | $119.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.97 / $114.93 / $162.30
| Professional | | $85.97 | $114.93 | $162.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $37.60 / $53.71 / $73.69
| Professional | 26 | $37.60 | $53.71 | $73.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $42.85 / $61.22 / $61.22
| Professional | TC | $42.85 | $61.22 | $61.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.62 / $127.72 / $214.47
| Professional | | $70.62 | $127.72 | $214.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $32.99 / $55.86 / $80.73
| Professional | 26 | $32.99 | $55.86 | $80.73 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $34.83 / $65.33 / $111.42
| Professional | TC | $34.83 | $65.33 | $111.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.26 / $102.48 / $187.18
| Professional | | $73.26 | $102.48 | $187.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.65 / $50.35 / $80.09
| Professional | 26 | $36.65 | $50.35 | $80.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $30.65 / $50.48 / $118.35
| Professional | TC | $30.65 | $50.48 | $118.35 |