- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Facility | 26 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $234.42 / $660.69
| Professional | | $95.50 | $234.42 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.31 / $97.72 / $263.03
| Professional | 26 | $36.31 | $97.72 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $56.23 / $81.28 / $263.03
| Professional | TC | $56.23 | $81.28 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $134.90 / $251.19
| Professional | | $102.33 | $134.90 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $50.12 / $85.11
| Professional | 26 | $34.67 | $50.12 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $60.26 / $85.11 / $117.49
| Professional | TC | $60.26 | $85.11 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $158.49 / $245.47
| Professional | | $97.72 | $158.49 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $38.02 / $58.88 / $89.13
| Professional | 26 | $38.02 | $58.88 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $58.88 / $104.71 / $158.49
| Professional | TC | $58.88 | $104.71 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $125.89 / $208.93
| Professional | | $81.28 | $125.89 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $37.15 / $48.98 / $77.62
| Professional | 26 | $37.15 | $48.98 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $43.65 / $81.28 / $141.25
| Professional | TC | $43.65 | $81.28 | $141.25 |