- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $31.63 / $31.63 / $31.63
| Facility | 26 | $31.63 | $31.63 | $31.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.08 / $161.19 / $198.64
| Professional | | $136.08 | $161.19 | $198.64 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $110.03 / $129.57 / $169.43
| Professional | TC | $110.03 | $129.57 | $169.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.43 / $201.49 / $330.02
| Professional | | $151.43 | $201.49 | $330.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $115.84 / $166.65 / $279.77
| Professional | TC | $115.84 | $166.65 | $279.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $130.29 / $194.69
| Professional | | $32.34 | $130.29 | $194.69 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $481.30 / $481.30 / $481.30
| Facility | 26 | $481.30 | $481.30 | $481.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.61 / $232.48 / $314.39
| Professional | | $197.61 | $232.48 | $314.39 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $168.71 / $198.48 / $257.58
| Professional | TC | $168.71 | $198.48 | $257.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.75 / $154.77 / $241.81
| Professional | | $108.75 | $154.77 | $241.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $86.44 / $134.10 / $207.73
| Professional | TC | $86.44 | $134.10 | $207.73 |