- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $153.47 / $153.47 / $153.47
| Facility | 26 | $153.47 | $153.47 | $153.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.21 / $191.59 / $197.23
| Professional | | $119.21 | $191.59 | $197.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $59.36 / $66.15 / $82.41
| Professional | 26 | $59.36 | $66.15 | $82.41 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $59.49 / $125.43 / $131.93
| Professional | TC | $59.49 | $125.43 | $131.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.92 / $177.33 / $233.37
| Professional | | $102.92 | $177.33 | $233.37 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.28 / $71.81 / $105.56
| Professional | 26 | $50.28 | $71.81 | $105.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $53.55 / $100.65 / $135.29
| Professional | TC | $53.55 | $100.65 | $135.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.57 / $194.91 / $308.68
| Professional | | $118.57 | $194.91 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.76 / $71.27 / $140.38
| Professional | 26 | $48.76 | $71.27 | $140.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $57.84 / $120.22 / $197.82
| Professional | TC | $57.84 | $120.22 | $197.82 |