- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $241.73 / $241.73 / $241.73
| Facility | 26 | $241.73 | $241.73 | $241.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.33 / $66.84 / $129.19
| Professional | | $39.33 | $66.84 | $129.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $26.87 / $37.32 / $46.70
| Professional | 26 | $26.87 | $37.32 | $46.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $7.43 / $20.25 / $91.87
| Professional | TC | $7.43 | $20.25 | $91.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.04 / $165.05 / $166.03
| Professional | | $110.04 | $165.05 | $166.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.44 / $47.77 / $90.37
| Professional | 26 | $33.44 | $47.77 | $90.37 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $82.10 / $117.29 / $150.13
| Professional | TC | $82.10 | $117.29 | $150.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.08 / $246.91 / $394.20
| Professional | | $102.08 | $246.91 | $394.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $49.76 / $80.88 / $108.69
| Professional | 26 | $49.76 | $80.88 | $108.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $19.42 / $166.03 / $285.51
| Professional | TC | $19.42 | $166.03 | $285.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.83 / $147.79 / $205.33
| Professional | | $89.83 | $147.79 | $205.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.99 / $58.59 / $67.27
| Professional | 26 | $36.99 | $58.59 | $67.27 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $34.26 / $103.55 / $138.06
| Professional | TC | $34.26 | $103.55 | $138.06 |