- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $23.68 / $23.68 / $23.68
| Facility | 26 | $23.68 | $23.68 | $23.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.12 / $185.44 / $1,258.16
| Professional | | $131.12 | $185.44 | $1,258.16 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $14.57 / $30.60 / $173.42
| Professional | 26 | $14.57 | $30.60 | $173.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $116.56 / $158.11 / $1,084.74
| Professional | TC | $116.56 | $158.11 | $1,084.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.11 / $224.24 / $325.18
| Professional | | $127.11 | $224.24 | $325.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.05 / $57.97 / $90.35
| Professional | 26 | $23.05 | $57.97 | $90.35 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $104.06 / $196.65 / $234.84
| Professional | TC | $104.06 | $196.65 | $234.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.87 / $20.87 / $20.87
| Professional | 26 | $20.87 | $20.87 | $20.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.17 / $122.52 / $294.60
| Professional | | $84.17 | $122.52 | $294.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $10.73 / $27.24 / $59.14
| Professional | 26 | $10.73 | $27.24 | $59.14 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $60.11 / $88.63 / $257.06
| Professional | TC | $60.11 | $88.63 | $257.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.21 / $193.20 / $350.12
| Professional | | $98.21 | $193.20 | $350.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $15.17 / $28.58 / $78.56
| Professional | 26 | $15.17 | $28.58 | $78.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $68.01 / $136.65 / $279.08
| Professional | TC | $68.01 | $136.65 | $279.08 |