- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $83.18 / $83.18 / $83.18
| Facility | 26 | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $478.63 / $1,000.00
| Professional | | $346.74 | $478.63 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $128.82 / $213.80
| Professional | 26 | $85.11 | $128.82 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $257.04 / $338.84 / $794.33
| Professional | TC | $257.04 | $338.84 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,348.96 / $2,570.40
| Professional | | $870.96 | $1,348.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $218.78 / $338.84 / $645.65
| Professional | 26 | $218.78 | $338.84 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $660.69 / $1,023.29 / $1,949.84
| Professional | TC | $660.69 | $1,023.29 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $794.33 / $1,412.54
| Professional | | $501.19 | $794.33 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $177.83 / $416.87
| Professional | 26 | $100.00 | $177.83 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $407.38 / $562.34 / $1,047.13
| Professional | TC | $407.38 | $562.34 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $707.95 / $1,778.28
| Professional | | $467.74 | $707.95 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $77.62 / $162.18 / $281.84
| Professional | 26 | $77.62 | $162.18 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $398.11 / $602.56 / $1,479.11
| Professional | TC | $398.11 | $602.56 | $1,479.11 |