- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $97.72 / $154.88
| Facility | 26 | $87.10 | $97.72 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $457.09 / $1,023.29
| Professional | | $323.59 | $457.09 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.13 / $87.10 / $165.96
| Professional | 26 | $74.13 | $87.10 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $229.09 / $354.81 / $691.83
| Professional | TC | $229.09 | $354.81 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $67.61 / $67.61
| Professional | 26 | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Professional | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $537.03 / $977.24
| Professional | | $323.59 | $537.03 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.13 / $125.89 / $173.78
| Professional | 26 | $74.13 | $125.89 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $263.03 / $426.58 / $812.83
| Professional | TC | $263.03 | $426.58 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $457.09 / $758.58
| Professional | | $302.00 | $457.09 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $87.10 / $177.83
| Professional | 26 | $63.10 | $87.10 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $234.42 / $371.54 / $575.44
| Professional | TC | $234.42 | $371.54 | $575.44 |