- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.90 / $46.77 / $54.95
| Facility | 26 | $38.90 | $46.77 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $165.96 / $407.38
| Professional | | $91.20 | $165.96 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $61.66 / $173.78
| Professional | 26 | $34.67 | $61.66 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $56.23 / $67.61 / $154.88
| Professional | TC | $56.23 | $67.61 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $109.65 / $204.17
| Professional | | $77.62 | $109.65 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.84 / $47.86 / $72.44
| Professional | 26 | $28.84 | $47.86 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $46.77 / $66.07 / $128.82
| Professional | TC | $46.77 | $66.07 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $263.03
| Professional | | $151.36 | $151.36 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.31 / $37.15 / $51.29
| Professional | 26 | $36.31 | $37.15 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $46.77 / $46.77 / $72.44
| Professional | TC | $46.77 | $46.77 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $114.82 / $208.93
| Professional | | $83.18 | $114.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $32.36 / $45.71 / $72.44
| Professional | 26 | $32.36 | $45.71 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $43.65 / $72.44 / $123.03
| Professional | TC | $43.65 | $72.44 | $123.03 |