- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $123.03 / $204.17 / $537.03
| Facility | 26 | $123.03 | $204.17 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $524.81 / $2,344.23
| Professional | | $371.54 | $524.81 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $208.93 / $549.54
| Professional | 26 | $114.82 | $208.93 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $251.19 / $338.84 / $724.44
| Professional | TC | $251.19 | $338.84 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $134.90 / $134.90 / $134.90
| Facility | 26 | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $549.54 / $1,174.90
| Professional | | $371.54 | $549.54 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $158.49 / $295.12
| Professional | 26 | $117.49 | $158.49 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $257.04 / $389.05 / $891.25
| Professional | TC | $257.04 | $389.05 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.20 / $158.49 / $389.05
| Facility | 26 | $30.20 | $158.49 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $645.65 / $1,202.26
| Professional | | $354.81 | $645.65 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $165.96 / $338.84
| Professional | 26 | $97.72 | $165.96 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $239.88 / $467.74 / $891.25
| Professional | TC | $239.88 | $467.74 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $549.54 / $1,023.29
| Professional | | $354.81 | $549.54 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $104.71 / $138.04 / $263.03
| Professional | 26 | $104.71 | $138.04 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $245.47 / $389.05 / $758.58
| Professional | TC | $245.47 | $389.05 | $758.58 |