- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $79.43 / $79.43
| Facility | 26 | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $158.49 / $295.12
| Professional | | $120.23 | $158.49 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $39.81 / $52.48 / $107.15
| Professional | 26 | $39.81 | $52.48 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $79.43 / $107.15 / $181.97
| Professional | TC | $79.43 | $107.15 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $31.62 / $53.70 / $63.10
| Professional | 26 | $31.62 | $53.70 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $141.25 / $154.88
| Professional | | $97.72 | $141.25 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $46.77 / $51.29
| Professional | 26 | $34.67 | $46.77 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $66.07 / $93.33 / $102.33
| Professional | TC | $66.07 | $93.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $186.21 / $371.54
| Professional | | $97.72 | $186.21 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $43.65 / $66.07 / $128.82
| Professional | 26 | $43.65 | $66.07 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $87.10 / $134.90 / $275.42
| Professional | TC | $87.10 | $134.90 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $144.54 / $263.03
| Professional | | $107.15 | $144.54 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $45.71 / $81.28
| Professional | 26 | $34.67 | $45.71 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $70.79 / $95.50 / $186.21
| Professional | TC | $70.79 | $95.50 | $186.21 |