- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $34.59 / $34.59 / $34.59
| Facility | 26 | $34.59 | $34.59 | $34.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.34 / $313.70 / $1,805.00
| Professional | | $68.34 | $313.70 | $1,805.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.59 / $186.93 / $684.00
| Professional | 26 | $34.59 | $186.93 | $684.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $35.34 / $44.02 / $940.00
| Professional | TC | $35.34 | $44.02 | $940.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.88 / $90.56 / $121.28
| Professional | | $77.88 | $90.56 | $121.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $39.02 / $42.14 / $60.77
| Professional | 26 | $39.02 | $42.14 | $60.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $38.85 / $47.69 / $61.67
| Professional | TC | $38.85 | $47.69 | $61.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.45 / $38.81 / $66.38
| Professional | | $24.45 | $38.81 | $66.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $230.90 / $230.90 / $230.90
| Facility | 26 | $230.90 | $230.90 | $230.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.15 / $121.23 / $128.87
| Professional | | $98.15 | $121.23 | $128.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.09 / $60.89 / $67.54
| Professional | 26 | $48.09 | $60.89 | $67.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $50.07 / $57.71 / $62.21
| Professional | TC | $50.07 | $57.71 | $62.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.84 / $84.81 / $112.80
| Professional | | $67.84 | $84.81 | $112.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.56 / $41.95 / $55.37
| Professional | 26 | $33.56 | $41.95 | $55.37 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $34.29 / $46.37 / $61.23
| Professional | TC | $34.29 | $46.37 | $61.23 |