- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $100.00 / $165.96
| Facility | 26 | $34.67 | $100.00 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $125.89 / $269.15
| Professional | | $85.11 | $125.89 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $30.20 / $46.77 / $218.78
| Professional | 26 | $30.20 | $46.77 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $57.54 / $87.10 / $199.53
| Professional | TC | $57.54 | $87.10 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $147.91 / $389.05
| Professional | | $89.13 | $147.91 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $24.55 / $43.65 / $134.90
| Professional | 26 | $24.55 | $43.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $64.57 / $93.33 / $263.03
| Professional | TC | $64.57 | $93.33 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $12.59 / $63.10 / $102.33
| Facility | 26 | $12.59 | $63.10 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $141.25 / $331.13
| Professional | | $66.07 | $141.25 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $19.95 / $42.66 / $104.71
| Professional | 26 | $19.95 | $42.66 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $42.66 / $95.50 / $218.78
| Professional | TC | $42.66 | $95.50 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $131.83 / $288.40
| Professional | | $75.86 | $131.83 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $24.55 / $42.66 / $95.50
| Professional | 26 | $24.55 | $42.66 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $51.29 / $91.20 / $199.53
| Professional | TC | $51.29 | $91.20 | $199.53 |