- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $19.95 / $30.90 / $81.28
| Facility | 26 | $19.95 | $30.90 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $239.88 / $758.58
| Professional | | $177.83 | $239.88 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $19.05 / $30.90 / $83.18
| Professional | 26 | $19.05 | $30.90 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $158.49 / $208.93 / $478.63
| Professional | TC | $158.49 | $208.93 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $288.40 / $549.54
| Professional | | $208.93 | $288.40 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $21.38 / $28.84 / $54.95
| Professional | 26 | $21.38 | $28.84 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $190.55 / $257.04 / $501.19
| Professional | TC | $190.55 | $257.04 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $5.62 / $32.36 / $100.00
| Facility | 26 | $5.62 | $32.36 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $354.81 / $645.65
| Professional | | $194.98 | $354.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.42 / $36.31 / $67.61
| Professional | 26 | $20.42 | $36.31 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $177.83 / $316.23 / $575.44
| Professional | TC | $177.83 | $316.23 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $269.15 / $537.03
| Professional | | $204.17 | $269.15 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.42 / $27.54 / $53.70
| Professional | 26 | $20.42 | $27.54 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $181.97 / $245.47 / $478.63
| Professional | TC | $181.97 | $245.47 | $478.63 |