- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $154.88 / $416.87
| Facility | 26 | $107.15 | $154.88 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $524.81 / $2,238.72
| Professional | | $346.74 | $524.81 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $177.83 / $501.19
| Professional | 26 | $97.72 | $177.83 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $245.47 / $354.81 / $933.25
| Professional | TC | $245.47 | $354.81 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Facility | 26 | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $549.54 / $1,445.44
| Professional | | $346.74 | $549.54 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.33 / $120.23 / $239.88
| Professional | 26 | $93.33 | $120.23 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $263.03 / $407.38 / $1,230.27
| Professional | TC | $263.03 | $407.38 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.12 / $131.83 / $323.59
| Facility | 26 | $25.12 | $131.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $676.08 / $1,412.54
| Professional | | $338.84 | $676.08 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $141.25 / $281.84
| Professional | 26 | $81.28 | $141.25 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $239.88 / $501.19 / $1,174.90
| Professional | TC | $239.88 | $501.19 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $562.34 / $1,174.90
| Professional | | $338.84 | $562.34 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $114.82 / $218.78
| Professional | 26 | $87.10 | $114.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $245.47 / $416.87 / $977.24
| Professional | TC | $245.47 | $416.87 | $977.24 |