- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $56.23 / $72.44
| Facility | 26 | $56.23 | $56.23 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $151.36 / $239.88
| Professional | | $112.20 | $151.36 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $46.77 / $75.86
| Professional | 26 | $34.67 | $46.77 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $72.44 / $107.15 / $158.49
| Professional | TC | $72.44 | $107.15 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $66.07 / $66.07
| Professional | 26 | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $190.55
| Professional | | $144.54 | $144.54 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.98 / $48.98 / $66.07
| Professional | 26 | $48.98 | $48.98 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $95.50 / $95.50 / $125.89
| Professional | TC | $95.50 | $95.50 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $208.93 / $309.03
| Professional | | $131.83 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $44.67 / $67.61 / $91.20
| Professional | 26 | $44.67 | $67.61 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $87.10 / $131.83 / $213.80
| Professional | TC | $87.10 | $131.83 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $181.97 / $302.00
| Professional | | $123.03 | $181.97 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $41.69 / $56.23 / $91.20
| Professional | 26 | $41.69 | $56.23 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $81.28 / $117.49 / $208.93
| Professional | TC | $81.28 | $117.49 | $208.93 |