- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $33.88 / $37.15 / $37.15
| Facility | 26 | $33.88 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $309.03 / $478.63
| Professional | | $251.19 | $309.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $30.20 / $57.54 / $75.86
| Professional | 26 | $30.20 | $57.54 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $223.87 / $275.42 / $398.11
| Professional | TC | $223.87 | $275.42 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $512.86 / $588.84
| Professional | | $77.62 | $512.86 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $8.51 / $39.81 / $56.23
| Facility | 26 | $8.51 | $39.81 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $912.01 / $1,348.96
| Professional | | $346.74 | $912.01 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $39.81 / $109.65 / $162.18
| Professional | 26 | $39.81 | $109.65 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $302.00 / $794.33 / $1,202.26
| Professional | TC | $302.00 | $794.33 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $70.79 / $87.10
| Professional | 26 | $58.88 | $70.79 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | TC | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $316.23 / $562.34
| Professional | | $194.98 | $316.23 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.99 / $32.36 / $61.66
| Professional | 26 | $23.99 | $32.36 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $173.78 / $281.84 / $512.86
| Professional | TC | $173.78 | $281.84 | $512.86 |