- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $54.67 / $54.67 / $54.67
| Facility | 26 | $54.67 | $54.67 | $54.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.64 / $245.74 / $389.72
| Professional | | $206.64 | $245.74 | $389.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $44.00 / $54.67 / $222.00
| Professional | 26 | $44.00 | $54.67 | $222.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $169.96 / $208.65 / $330.64
| Professional | TC | $169.96 | $208.65 | $330.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.14 / $381.17 / $529.73
| Professional | | $300.14 | $381.17 | $529.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.98 / $63.66 / $93.99
| Professional | 26 | $52.98 | $63.66 | $93.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $249.65 / $317.50 / $457.50
| Professional | TC | $249.65 | $317.50 | $457.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $184.69 / $263.94
| Professional | | $32.34 | $184.69 | $263.94 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $418.84 / $418.84 / $418.84
| Facility | 26 | $418.84 | $418.84 | $418.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.80 / $409.44 / $545.29
| Professional | | $314.80 | $409.44 | $545.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.02 / $67.66 / $85.42
| Professional | 26 | $52.02 | $67.66 | $85.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $262.77 / $341.78 / $467.01
| Professional | TC | $262.77 | $341.78 | $467.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.92 / $331.50 / $501.07
| Professional | | $249.92 | $331.50 | $501.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.88 / $56.58 / $80.23
| Professional | 26 | $42.88 | $56.58 | $80.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $206.25 / $284.58 / $436.00
| Professional | TC | $206.25 | $284.58 | $436.00 |