- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $31.81 / $31.81 / $31.81
| Facility | 26 | $31.81 | $31.81 | $31.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.76 / $118.78 / $798.41
| Professional | | $71.76 | $118.78 | $798.41 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $19.67 / $36.64 / $226.66
| Professional | 26 | $19.67 | $36.64 | $226.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $52.09 / $83.13 / $571.69
| Professional | TC | $52.09 | $83.13 | $571.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.15 / $121.08 / $151.86
| Professional | | $79.15 | $121.08 | $151.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $27.22 / $39.06 / $44.44
| Professional | 26 | $27.22 | $39.06 | $44.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $52.51 / $76.63 / $112.14
| Professional | TC | $52.51 | $76.63 | $112.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $30.17 / $30.17 / $30.17
| Professional | 26 | $30.17 | $30.17 | $30.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $60.09 / $208.97
| Professional | | $33.88 | $60.09 | $208.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.29 / $16.98 / $63.03
| Professional | 26 | $12.29 | $16.98 | $63.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $21.60 / $42.21 / $146.18
| Professional | TC | $21.60 | $42.21 | $146.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.50 / $112.06 / $209.67
| Professional | | $59.50 | $112.06 | $209.67 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $18.64 / $33.63 / $62.92
| Professional | 26 | $18.64 | $33.63 | $62.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $36.54 / $78.43 / $146.75
| Professional | TC | $36.54 | $78.43 | $146.75 |