- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $17.27 / $17.27 / $17.55
| Facility | 26 | $17.27 | $17.27 | $17.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.19 / $103.93 / $132.21
| Professional | | $77.19 | $103.93 | $132.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $14.49 / $17.67 / $20.22
| Professional | 26 | $14.49 | $17.67 | $20.22 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $62.70 / $87.32 / $113.77
| Professional | TC | $62.70 | $87.32 | $113.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.00 / $423.00 / $423.00
| Professional | | $258.00 | $423.00 | $423.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $45.00 / $74.00 / $74.00
| Professional | 26 | $45.00 | $74.00 | $74.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $213.00 / $349.00 / $349.00
| Professional | TC | $213.00 | $349.00 | $349.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.87 / $134.37 / $200.18
| Professional | | $91.87 | $134.37 | $200.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.93 / $27.67 / $43.73
| Professional | 26 | $20.93 | $27.67 | $43.73 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $67.03 / $100.55 / $157.34
| Professional | TC | $67.03 | $100.55 | $157.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.61 / $171.37 / $316.79
| Professional | | $114.61 | $171.37 | $316.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $18.72 / $33.60 / $62.71
| Professional | 26 | $18.72 | $33.60 | $62.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $86.28 / $138.15 / $304.19
| Professional | TC | $86.28 | $138.15 | $304.19 |