- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Facility | 26 | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $616.60 / $2,041.74
| Professional | | $371.54 | $616.60 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $151.36 / $295.12
| Professional | 26 | $85.11 | $151.36 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $257.04 / $436.52 / $1,023.29
| Professional | TC | $257.04 | $436.52 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $512.86 / $954.99
| Professional | | $380.19 | $512.86 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $109.65 / $177.83
| Professional | 26 | $85.11 | $109.65 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $275.42 / $363.08 / $457.09
| Professional | TC | $275.42 | $363.08 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $741.31 / $1,445.44
| Professional | | $436.52 | $741.31 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $72.44 / $165.96 / $190.55
| Professional | 26 | $72.44 | $165.96 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $338.84 / $562.34 / $1,258.93
| Professional | TC | $338.84 | $562.34 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $691.83 / $1,047.13
| Professional | | $398.11 | $691.83 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $102.33 / $165.96
| Professional | 26 | $79.43 | $102.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $302.00 / $446.68 / $812.83
| Professional | TC | $302.00 | $446.68 | $812.83 |