- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.57 / $107.15 / $107.15
| Facility | 26 | $64.57 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $501.19 / $1,258.93
| Professional | | $331.13 | $501.19 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.18 / $138.04 / $218.78
| Professional | 26 | $69.18 | $138.04 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $239.88 / $371.54 / $776.25
| Professional | TC | $239.88 | $371.54 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $61.66 / $81.28 / $97.72
| Professional | 26 | $61.66 | $81.28 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $524.81 / $616.60
| Professional | | $190.55 | $524.81 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.20 / $158.49 / $204.17
| Professional | 26 | $112.20 | $158.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $131.83 / $363.08 / $426.58
| Professional | TC | $131.83 | $363.08 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $660.69 / $1,318.26
| Professional | | $371.54 | $660.69 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $72.44 / $120.23 / $213.80
| Professional | 26 | $72.44 | $120.23 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $302.00 / $537.03 / $1,148.15
| Professional | TC | $302.00 | $537.03 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $416.87 / $1,202.26
| Professional | | $288.40 | $416.87 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $75.86 / $131.83
| Professional | 26 | $57.54 | $75.86 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $234.42 / $331.13 / $1,023.29
| Professional | TC | $234.42 | $331.13 | $1,023.29 |