- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $626.64 / $626.64 / $626.64
| Facility | 26 | $626.64 | $626.64 | $626.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.07 / $907.55 / $1,063.64
| Professional | | $613.07 | $907.55 | $1,063.64 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $534.46 / $806.69 / $939.54
| Professional | TC | $534.46 | $806.69 | $939.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.79 / $1,133.42 / $1,523.64
| Professional | | $1,110.79 | $1,133.42 | $1,523.64 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $711.68 / $1,016.68 / $1,095.88
| Professional | TC | $711.68 | $1,016.68 | $1,095.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.64 / $1,743.46 / $2,775.22
| Professional | | $1,180.64 | $1,743.46 | $2,775.22 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $1,059.03 / $1,533.78 / $2,510.52
| Professional | TC | $1,059.03 | $1,533.78 | $2,510.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.56 / $1,087.40 / $1,449.87
| Professional | | $259.56 | $1,087.40 | $1,449.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $510.28 / $1,045.16 / $1,275.50
| Professional | TC | $510.28 | $1,045.16 | $1,275.50 |