- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $87.10 / $91.20
| Facility | 26 | $87.10 | $87.10 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $446.68 / $831.76
| Professional | | $346.74 | $446.68 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $100.00 / $245.47
| Professional | 26 | $79.43 | $100.00 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $281.84 / $354.81 / $457.09
| Professional | TC | $281.84 | $354.81 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,148.15
| Professional | | $776.25 | $1,023.29 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $144.54 / $194.98 / $213.80
| Professional | 26 | $144.54 | $194.98 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $630.96 / $831.76 / $933.25
| Professional | TC | $630.96 | $831.76 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $851.14 / $1,258.93
| Professional | | $331.13 | $851.14 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $162.18 / $229.09
| Professional | 26 | $97.72 | $162.18 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $269.15 / $691.83 / $1,023.29
| Professional | TC | $269.15 | $691.83 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $741.31 / $2,754.23
| Professional | | $416.87 | $741.31 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $165.96 / $776.25
| Professional | 26 | $89.13 | $165.96 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $323.59 / $588.84 / $2,187.76
| Professional | TC | $323.59 | $588.84 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $741.31 / $1,148.15
| Professional | | $416.87 | $741.31 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $162.18 / $218.78
| Professional | 26 | $89.13 | $162.18 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $323.59 / $588.84 / $933.25
| Professional | TC | $323.59 | $588.84 | $933.25 |