- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,377.81 / $1,377.81 / $1,377.81
| Facility | 26 | $1,377.81 | $1,377.81 | $1,377.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.23 / $557.72 / $867.93
| Professional | | $323.23 | $557.72 | $867.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $150.16 / $210.58 / $388.55
| Professional | 26 | $150.16 | $210.58 | $388.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $173.06 / $306.66 / $384.32
| Professional | TC | $173.06 | $306.66 | $384.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.78 / $584.29 / $1,199.40
| Professional | | $517.78 | $584.29 | $1,199.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $189.74 / $271.06 / $460.67
| Professional | 26 | $189.74 | $271.06 | $460.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $219.28 / $313.25 / $639.05
| Professional | TC | $219.28 | $313.25 | $639.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.65 / $996.87 / $1,354.15
| Professional | | $608.65 | $996.87 | $1,354.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $282.35 / $461.02 / $618.95
| Professional | 26 | $282.35 | $461.02 | $618.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $326.30 / $535.85 / $735.20
| Professional | TC | $326.30 | $535.85 | $735.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.04 / $810.86 / $1,366.60
| Professional | | $498.04 | $810.86 | $1,366.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $200.34 / $334.90 / $383.39
| Professional | 26 | $200.34 | $334.90 | $383.39 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $265.62 / $445.60 / $935.69
| Professional | TC | $265.62 | $445.60 | $935.69 |