- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.40 / $60.40 / $60.40
| Facility | 26 | $60.40 | $60.40 | $60.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.57 / $325.99 / $351.15
| Professional | | $305.57 | $325.99 | $351.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $55.42 / $57.46 / $60.40
| Professional | 26 | $55.42 | $57.46 | $60.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $250.15 / $265.60 / $295.56
| Professional | TC | $250.15 | $265.60 | $295.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.17 / $470.39 / $1,412.96
| Professional | | $395.17 | $470.39 | $1,412.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $77.81 / $91.72 / $202.53
| Professional | 26 | $77.81 | $91.72 | $202.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $333.44 / $333.44 / $402.24
| Professional | TC | $333.44 | $333.44 | $402.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.02 / $478.37 / $1,412.96
| Professional | | $241.02 | $478.37 | $1,412.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.93 / $79.61 / $202.53
| Professional | 26 | $42.93 | $79.61 | $202.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $180.81 / $403.02 / $701.19
| Professional | TC | $180.81 | $403.02 | $701.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.81 / $497.60 / $831.76
| Professional | | $237.81 | $497.60 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $68.79 / $80.06 / $130.57
| Professional | 26 | $68.79 | $80.06 | $130.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $180.81 / $416.67 / $678.54
| Professional | TC | $180.81 | $416.67 | $678.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.71 / $480.08 / $1,518.68
| Professional | | $252.71 | $480.08 | $1,518.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.69 / $82.01 / $238.41
| Professional | 26 | $74.69 | $82.01 | $238.41 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $192.07 / $440.40 / $1,280.27
| Professional | TC | $192.07 | $440.40 | $1,280.27 |