- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $123.03 / $147.91 / $147.91
| Facility | 26 | $123.03 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $151.36 / $208.93
| Professional | | $100.00 | $151.36 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $34.67 / $54.95 / $70.79
| Professional | TC | $34.67 | $54.95 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $169.82 / $213.80
| Professional | | $147.91 | $169.82 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $46.77 / $52.48 / $67.61
| Professional | TC | $46.77 | $52.48 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $218.78 / $295.12
| Professional | | $147.91 | $218.78 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $53.70 / $75.86 / $109.65
| Professional | TC | $53.70 | $75.86 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $173.78 / $275.42
| Professional | | $131.83 | $173.78 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $44.67 / $57.54 / $100.00
| Professional | TC | $44.67 | $57.54 | $100.00 |