- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.34 / $57.34 / $57.34
| Facility | 26 | $57.34 | $57.34 | $57.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.26 / $501.83 / $715.93
| Professional | | $405.26 | $501.83 | $715.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $40.70 / $46.29 / $67.38
| Professional | 26 | $40.70 | $46.29 | $67.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $361.00 / $427.68 / $643.03
| Professional | TC | $361.00 | $427.68 | $643.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.92 / $550.58 / $1,026.28
| Professional | | $259.92 | $550.58 | $1,026.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $24.34 / $58.44 / $107.87
| Professional | 26 | $24.34 | $58.44 | $107.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $235.58 / $512.63 / $985.37
| Professional | TC | $235.58 | $512.63 | $985.37 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $89.93 / $89.93 / $89.93
| Facility | 26 | $89.93 | $89.93 | $89.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.54 / $513.28 / $913.62
| Professional | | $299.54 | $513.28 | $913.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $29.33 / $53.33 / $96.53
| Professional | 26 | $29.33 | $53.33 | $96.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $263.75 / $458.30 / $820.23
| Professional | TC | $263.75 | $458.30 | $820.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.31 / $539.50 / $1,060.81
| Professional | | $336.31 | $539.50 | $1,060.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.94 / $54.65 / $115.04
| Professional | 26 | $34.94 | $54.65 | $115.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $288.67 / $480.47 / $938.07
| Professional | TC | $288.67 | $480.47 | $938.07 |