- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $81.28 / $81.28
| Facility | 26 | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $478.63 / $691.83
| Professional | | $275.42 | $478.63 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $141.25 / $213.80
| Professional | 26 | $85.11 | $141.25 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $190.55 / $302.00 / $478.63
| Professional | TC | $190.55 | $302.00 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,096.48 / $2,089.30
| Professional | | $707.95 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $218.78 / $338.84 / $630.96
| Professional | 26 | $218.78 | $338.84 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $489.78 / $758.58 / $1,445.44
| Professional | TC | $489.78 | $758.58 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $645.65 / $1,288.25
| Professional | | $416.87 | $645.65 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $177.83 / $371.54
| Professional | 26 | $97.72 | $177.83 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $295.12 / $467.74 / $1,047.13
| Professional | TC | $295.12 | $467.74 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $645.65 / $1,698.24
| Professional | | $489.78 | $645.65 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.86 / $162.18 / $288.40
| Professional | 26 | $75.86 | $162.18 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $363.08 / $457.09 / $1,412.54
| Professional | TC | $363.08 | $457.09 | $1,412.54 |