- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Facility | 26 | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $275.42 / $478.63
| Professional | | $186.21 | $275.42 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $123.03 / $295.12
| Professional | 26 | $54.95 | $123.03 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $100.00 / $141.25 / $239.88
| Professional | TC | $100.00 | $141.25 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $158.49 / $158.49 / $158.49
| Professional | 26 | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $467.74 / $562.34
| Professional | | $173.78 | $467.74 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $104.71 / $151.36 / $190.55
| Professional | 26 | $104.71 | $151.36 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $117.49 / $323.59 / $380.19
| Professional | TC | $117.49 | $323.59 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $537.03 / $1,288.25
| Professional | | $288.40 | $537.03 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $138.04 / $302.00
| Professional | 26 | $81.28 | $138.04 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $208.93 / $380.19 / $933.25
| Professional | TC | $208.93 | $380.19 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $457.09 / $660.69
| Professional | | $316.23 | $457.09 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $117.49 / $177.83
| Professional | 26 | $89.13 | $117.49 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $229.09 / $331.13 / $501.19
| Professional | TC | $229.09 | $331.13 | $501.19 |