- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.71 / $154.88 / $407.38
| Facility | 26 | $104.71 | $154.88 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $478.63 / $1,479.11
| Professional | | $199.53 | $478.63 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $181.97 / $512.86
| Professional | 26 | $97.72 | $181.97 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $245.47 / $346.74 / $870.96
| Professional | TC | $245.47 | $346.74 | $870.96 |
- 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
- $338.84 / $524.81 / $1,202.26
| Professional | | $338.84 | $524.81 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.33 / $123.03 / $239.88
| Professional | 26 | $93.33 | $123.03 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $257.04 / $407.38 / $1,000.00
| Professional | TC | $257.04 | $407.38 | $1,000.00 |
- 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 / $660.69 / $1,380.38
| Professional | | $338.84 | $660.69 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $141.25 / $281.84
| Professional | 26 | $83.18 | $141.25 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $239.88 / $512.86 / $1,174.90
| Professional | TC | $239.88 | $512.86 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $575.44 / $1,202.26
| Professional | | $338.84 | $575.44 | $1,202.26 |
- 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 / $426.58 / $977.24
| Professional | TC | $245.47 | $426.58 | $977.24 |