- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $117.11 / $342.94 / $4,509.09
| Facility | 26 | $117.11 | $342.94 | $4,509.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.14 / $761.38 / $1,065.40
| Professional | | $554.14 | $761.38 | $1,065.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.06 / $131.91 / $353.67
| Professional | 26 | $112.06 | $131.91 | $353.67 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $274.11 / $331.16 / $403.57
| Professional | 52 | $274.11 | $331.16 | $403.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $442.08 / $629.47 / $884.77
| Professional | TC | $442.08 | $629.47 | $884.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.08 / $845.87 / $1,097.08
| Professional | | $563.08 | $845.87 | $1,097.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $101.35 / $168.62 / $218.88
| Professional | 26 | $101.35 | $168.62 | $218.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $442.80 / $677.24 / $886.98
| Professional | TC | $442.80 | $677.24 | $886.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.00 / $1,075.00 / $1,075.00
| Professional | | $1,075.00 | $1,075.00 | $1,075.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.08 / $117.08 / $117.08
| Professional | 26 | $117.08 | $117.08 | $117.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.41 / $818.23 / $1,392.18
| Professional | | $513.41 | $818.23 | $1,392.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $96.64 / $137.38 / $276.72
| Professional | 26 | $96.64 | $137.38 | $276.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $424.59 / $544.47 / $1,115.46
| Professional | TC | $424.59 | $544.47 | $1,115.46 |