- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $41.97 / $44.06 / $44.06
| Facility | 26 | $41.97 | $44.06 | $44.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.21 / $216.85 / $216.85
| Professional | | $156.21 | $216.85 | $216.85 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $123.80 / $172.79 / $172.79
| Professional | TC | $123.80 | $172.79 | $172.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.01 / $300.73 / $439.21
| Professional | | $224.01 | $300.73 | $439.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $179.76 / $241.33 / $352.45
| Professional | TC | $179.76 | $241.33 | $352.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.08 / $299.02 / $512.02
| Professional | | $213.08 | $299.02 | $512.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $171.25 / $221.75 / $387.49
| Professional | TC | $171.25 | $221.75 | $387.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.08 / $382.08 / $409.78
| Professional | | $382.08 | $382.08 | $409.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.53 / $326.32 / $404.03
| Professional | | $206.53 | $326.32 | $404.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $41.97 / $66.31 / $81.84
| Professional | 26 | $41.97 | $66.31 | $81.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $164.56 / $260.00 / $324.10
| Professional | TC | $164.56 | $260.00 | $324.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.05 / $334.39 / $576.53
| Professional | | $217.05 | $334.39 | $576.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $175.66 / $295.07 / $461.05
| Professional | TC | $175.66 | $295.07 | $461.05 |