- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.44 / $112.20 / $295.12
| Facility | 26 | $72.44 | $112.20 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $436.52 / $1,698.24
| Professional | | $302.00 | $436.52 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $61.66 / $87.10 / $263.03
| Professional | 26 | $61.66 | $87.10 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $239.88 / $354.81 / $707.95
| Professional | TC | $239.88 | $354.81 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $489.78 / $1,047.13
| Professional | | $354.81 | $489.78 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $95.50 / $194.98
| Professional | 26 | $67.61 | $95.50 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $281.84 / $407.38 / $870.96
| Professional | TC | $281.84 | $407.38 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $17.78 / $100.00 / $316.23
| Facility | 26 | $17.78 | $100.00 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $630.96 / $1,202.26
| Professional | | $331.13 | $630.96 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $64.57 / $114.82 / $213.80
| Professional | 26 | $64.57 | $114.82 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $281.84 / $537.03 / $977.24
| Professional | TC | $281.84 | $537.03 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $478.63 / $954.99
| Professional | | $338.84 | $478.63 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $89.13 / $173.78
| Professional | 26 | $66.07 | $89.13 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $263.03 / $389.05 / $794.33
| Professional | TC | $263.03 | $389.05 | $794.33 |