- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $141.35 / $168.77 / $181.43
| Facility | 26 | $141.35 | $168.77 | $181.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.22 / $1,238.78 / $1,362.66
| Professional | | $1,045.22 | $1,238.78 | $1,362.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $902.82 / $1,070.01 / $1,177.01
| Professional | TC | $902.82 | $1,070.01 | $1,177.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.23 / $1,200.61 / $1,460.71
| Professional | | $1,067.23 | $1,200.61 | $1,460.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $928.34 / $1,066.24 / $1,293.58
| Professional | TC | $928.34 | $1,066.24 | $1,293.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.39 / $889.36 / $1,774.87
| Professional | | $568.39 | $889.36 | $1,774.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $470.64 / $764.05 / $1,563.69
| Professional | TC | $470.64 | $764.05 | $1,563.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.06 / $799.81 / $1,335.34
| Professional | | $250.06 | $799.81 | $1,335.34 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $334.13 / $699.16 / $1,153.42
| Professional | TC | $334.13 | $699.16 | $1,153.42 |