- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $69.25 / $87.25 / $87.25
| Facility | 26 | $69.25 | $87.25 | $87.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.97 / $152.99 / $264.20
| Professional | | $113.97 | $152.99 | $264.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $55.39 / $69.25 / $165.02
| Professional | 26 | $55.39 | $69.25 | $165.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $56.40 / $89.31 / $181.88
| Professional | TC | $56.40 | $89.31 | $181.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.65 / $116.98 / $209.15
| Professional | | $86.65 | $116.98 | $209.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.74 / $93.74 / $93.74
| Professional | 26 | $93.74 | $93.74 | $93.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.87 / $67.87 / $67.87
| Facility | 26 | $67.87 | $67.87 | $67.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.30 / $178.89 / $339.49
| Professional | | $114.30 | $178.89 | $339.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.20 / $74.13 / $171.66
| Professional | 26 | $58.20 | $74.13 | $171.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $55.90 / $93.23 / $190.01
| Professional | TC | $55.90 | $93.23 | $190.01 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.98 / $60.98 / $87.25
| Facility | 26 | $60.98 | $60.98 | $87.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $168.92 / $228.04
| Professional | | $127.38 | $168.92 | $228.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $59.09 / $66.15 / $119.64
| Professional | 26 | $59.09 | $66.15 | $119.64 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $61.63 / $107.94 / $134.91
| Professional | TC | $61.63 | $107.94 | $134.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.56 / $78.92 / $121.67
| Professional | | $36.56 | $78.92 | $121.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.76 / $164.23 / $236.37
| Professional | | $124.76 | $164.23 | $236.37 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.01 / $71.37 / $103.50
| Professional | 26 | $60.01 | $71.37 | $103.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $61.58 / $88.11 / $138.47
| Professional | TC | $61.58 | $88.11 | $138.47 |