- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $97.72 / $97.72
| Facility | 26 | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $426.58 / $1,000.00
| Professional | | $194.98 | $426.58 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $218.78 / $354.81
| Professional | 26 | $97.72 | $218.78 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $295.12 / $371.54 / $741.31
| Professional | TC | $295.12 | $371.54 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $2,951.21
| Professional | | $1,000.00 | $1,548.82 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $263.03 / $407.38 / $776.25
| Professional | 26 | $263.03 | $407.38 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $741.31 / $1,148.15 / $2,187.76
| Professional | TC | $741.31 | $1,148.15 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $933.25 / $1,584.89
| Professional | | $602.56 | $933.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $213.80 / $416.87
| Professional | 26 | $117.49 | $213.80 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $467.74 / $676.08 / $1,230.27
| Professional | TC | $467.74 | $676.08 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $933.25 / $2,137.96
| Professional | | $602.56 | $933.25 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $190.55 / $346.74
| Professional | 26 | $91.20 | $190.55 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $512.86 / $707.95 / $1,819.70
| Professional | TC | $512.86 | $707.95 | $1,819.70 |