- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $127.77 / $127.77 / $127.77
| Facility | 26 | $127.77 | $127.77 | $127.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.95 / $212.78 / $464.18
| Professional | | $166.95 | $212.78 | $464.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.57 / $104.72 / $151.62
| Professional | 26 | $91.57 | $104.72 | $151.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $75.68 / $94.71 / $130.38
| Professional | TC | $75.68 | $94.71 | $130.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.06 / $244.87 / $503.04
| Professional | | $109.06 | $244.87 | $503.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $51.84 / $132.54 / $245.31
| Professional | 26 | $51.84 | $132.54 | $245.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $58.27 / $112.69 / $237.66
| Professional | TC | $58.27 | $112.69 | $237.66 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $138.13 / $138.13 / $138.13
| Facility | 26 | $138.13 | $138.13 | $138.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.16 / $227.10 / $439.82
| Professional | | $114.16 | $227.10 | $439.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $63.29 / $120.94 / $242.07
| Professional | 26 | $63.29 | $120.94 | $242.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $50.23 / $95.44 / $216.00
| Professional | TC | $50.23 | $95.44 | $216.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.11 / $230.99 / $449.17
| Professional | | $141.11 | $230.99 | $449.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $78.68 / $131.86 / $248.80
| Professional | 26 | $78.68 | $131.86 | $248.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $63.88 / $99.90 / $212.94
| Professional | TC | $63.88 | $99.90 | $212.94 |