- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Facility | 26 | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $234.42 / $954.99
| Professional | | $199.53 | $234.42 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $53.70 / $63.10 / $134.90
| Professional | 26 | $53.70 | $63.10 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $147.91 / $173.78 / $446.68
| Professional | TC | $147.91 | $173.78 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $831.76 / $831.76
| Professional | | $446.68 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $123.03 / $234.42 / $234.42
| Professional | 26 | $123.03 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $323.59 / $602.56 / $602.56
| Professional | TC | $323.59 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $512.86 / $1,000.00
| Professional | | $239.88 | $512.86 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $97.72 / $229.09
| Professional | 26 | $66.07 | $97.72 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $169.82 / $363.08 / $891.25
| Professional | TC | $169.82 | $363.08 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $426.58 / $2,089.30
| Professional | | $371.54 | $426.58 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $51.29 / $109.65 / $194.98
| Professional | 26 | $51.29 | $109.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $269.15 / $363.08 / $1,905.46
| Professional | TC | $269.15 | $363.08 | $1,905.46 |