- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | 26 | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $831.76 / $2,630.27
| Professional | | $371.54 | $831.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.20 / $194.98 / $371.54
| Professional | 26 | $112.20 | $194.98 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $257.04 / $457.09 / $1,023.29
| Professional | TC | $257.04 | $457.09 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $691.83 / $1,230.27
| Professional | | $512.86 | $691.83 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $138.04 / $218.78
| Professional | 26 | $107.15 | $138.04 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $380.19 / $478.63 / $602.56
| Professional | TC | $380.19 | $478.63 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,000.00 / $1,479.11
| Professional | | $467.74 | $1,000.00 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $204.17 / $234.42
| Professional | 26 | $91.20 | $204.17 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $380.19 / $794.33 / $1,288.25
| Professional | TC | $380.19 | $794.33 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $812.83 / $1,230.27
| Professional | | $562.34 | $812.83 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $128.82 / $208.93
| Professional | 26 | $97.72 | $128.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $436.52 / $645.65 / $954.99
| Professional | TC | $436.52 | $645.65 | $954.99 |