- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $94.73 / $94.73 / $96.41
| Facility | 26 | $94.73 | $94.73 | $96.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.20 / $910.20 / $1,026.58
| Professional | | $910.20 | $910.20 | $1,026.58 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $815.48 / $815.48 / $925.33
| Professional | TC | $815.48 | $815.48 | $925.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,992.00 / $3,575.00 / $3,575.00
| Professional | | $1,992.00 | $3,575.00 | $3,575.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $1,786.00 / $3,205.00 / $3,205.00
| Professional | TC | $1,786.00 | $3,205.00 | $3,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.66 / $1,105.19 / $3,137.04
| Professional | | $995.66 | $1,105.19 | $3,137.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $854.73 / $928.78 / $2,826.46
| Professional | TC | $854.73 | $928.78 | $2,826.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.65 / $1,440.00 / $2,598.44
| Professional | | $654.65 | $1,440.00 | $2,598.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $531.48 / $1,263.60 / $2,280.15
| Professional | TC | $531.48 | $1,263.60 | $2,280.15 |