- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $47.53 / $47.53 / $47.53
| Facility | 26 | $47.53 | $47.53 | $47.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.95 / $454.67 / $3,108.07
| Professional | | $272.95 | $454.67 | $3,108.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $29.35 / $54.80 / $339.95
| Professional | 26 | $29.35 | $54.80 | $339.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $243.61 / $401.21 / $2,768.05
| Professional | TC | $243.61 | $401.21 | $2,768.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.80 / $492.50 / $677.47
| Professional | | $393.80 | $492.50 | $677.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $44.72 / $57.35 / $86.08
| Professional | 26 | $44.72 | $57.35 | $86.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $349.08 / $435.14 / $609.84
| Professional | TC | $349.08 | $435.14 | $609.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $43.00 / $43.00 / $43.00
| Professional | 26 | $43.00 | $43.00 | $43.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.25 / $247.79 / $848.08
| Professional | | $175.25 | $247.79 | $848.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.05 / $32.97 / $94.70
| Professional | 26 | $22.05 | $32.97 | $94.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $153.21 / $222.57 / $753.38
| Professional | TC | $153.21 | $222.57 | $753.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.39 / $469.27 / $839.83
| Professional | | $245.39 | $469.27 | $839.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $29.62 / $50.89 / $94.36
| Professional | 26 | $29.62 | $50.89 | $94.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $214.52 / $472.32 / $708.19
| Professional | TC | $214.52 | $472.32 | $708.19 |