- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $192.22 / $192.22 / $192.22
| Facility | 26 | $192.22 | $192.22 | $192.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.97 / $124.42 / $727.98
| Professional | | $51.97 | $124.42 | $727.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.29 / $31.37 / $115.89
| Professional | 26 | $23.29 | $31.37 | $115.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $28.68 / $93.04 / $95.69
| Professional | TC | $28.68 | $93.04 | $95.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.13 / $124.86 / $250.47
| Professional | | $106.13 | $124.86 | $250.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $26.05 / $37.21 / $59.94
| Professional | 26 | $26.05 | $37.21 | $59.94 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $61.36 / $87.65 / $87.65
| Professional | TC | $61.36 | $87.65 | $87.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.57 / $136.05 / $214.33
| Professional | | $88.57 | $136.05 | $214.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.79 / $43.85 / $64.31
| Professional | 26 | $28.79 | $43.85 | $64.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $48.31 / $98.00 / $150.01
| Professional | TC | $48.31 | $98.00 | $150.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.74 / $117.51 / $193.91
| Professional | | $84.74 | $117.51 | $193.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.80 / $40.11 / $59.28
| Professional | 26 | $28.80 | $40.11 | $59.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $56.59 / $80.67 / $135.11
| Professional | TC | $56.59 | $80.67 | $135.11 |