- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $80.00 / $101.96 / $185.80
| Facility | 26 | $80.00 | $101.96 | $185.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.29 / $540.34 / $1,294.35
| Professional | | $409.29 | $540.34 | $1,294.35 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.73 / $87.61 / $211.68
| Professional | 26 | $67.73 | $87.61 | $211.68 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $350.32 / $444.17 / $778.11
| Professional | TC | $350.32 | $444.17 | $778.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.66 / $543.89 / $910.98
| Professional | | $414.66 | $543.89 | $910.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.01 / $100.26 / $156.19
| Professional | 26 | $80.01 | $100.26 | $156.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $337.44 / $457.73 / $750.09
| Professional | TC | $337.44 | $457.73 | $750.09 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $93.59 / $93.59 / $93.59
| Facility | 26 | $93.59 | $93.59 | $93.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.52 / $640.41 / $1,122.63
| Professional | | $426.52 | $640.41 | $1,122.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $77.65 / $112.75 / $188.00
| Professional | 26 | $77.65 | $112.75 | $188.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $333.91 / $544.92 / $949.66
| Professional | TC | $333.91 | $544.92 | $949.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.52 / $607.58 / $1,013.13
| Professional | | $418.52 | $607.58 | $1,013.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $76.20 / $102.21 / $166.08
| Professional | 26 | $76.20 | $102.21 | $166.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $351.98 / $516.65 / $824.79
| Professional | TC | $351.98 | $516.65 | $824.79 |