- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $33.17 / $33.17 / $33.17
| Facility | 26 | $33.17 | $33.17 | $33.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.48 / $127.68 / $788.06
| Professional | | $70.48 | $127.68 | $788.06 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.52 / $42.37 / $238.87
| Professional | 26 | $20.52 | $42.37 | $238.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $49.96 / $85.31 / $549.19
| Professional | TC | $49.96 | $85.31 | $549.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.49 / $132.80 / $320.26
| Professional | | $91.49 | $132.80 | $320.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $31.55 / $43.75 / $119.77
| Professional | 26 | $31.55 | $43.75 | $119.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $59.94 / $93.08 / $228.82
| Professional | TC | $59.94 | $93.08 | $228.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $29.40 / $29.40 / $29.40
| Professional | 26 | $29.40 | $29.40 | $29.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.05 / $121.90 / $254.49
| Professional | | $48.05 | $121.90 | $254.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $15.10 / $30.83 / $70.73
| Professional | 26 | $15.10 | $30.83 | $70.73 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $32.95 / $76.72 / $191.96
| Professional | TC | $32.95 | $76.72 | $191.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.58 / $138.16 / $345.06
| Professional | | $63.58 | $138.16 | $345.06 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.90 / $42.81 / $87.38
| Professional | 26 | $20.90 | $42.81 | $87.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $41.95 / $87.34 / $251.66
| Professional | TC | $41.95 | $87.34 | $251.66 |