- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $288.02 / $330.83 / $850.25
| Facility | 26 | $288.02 | $330.83 | $850.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.33 / $1,133.92 / $1,253.22
| Professional | | $1,049.33 | $1,133.92 | $1,253.22 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $309.57 / $318.66 / $330.84
| Professional | 26 | $309.57 | $318.66 | $330.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $739.76 / $815.25 / $922.38
| Professional | TC | $739.76 | $815.25 | $922.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.14 / $1,343.31 / $1,700.17
| Professional | | $1,092.14 | $1,343.31 | $1,700.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $275.86 / $407.35 / $458.86
| Professional | 26 | $275.86 | $407.35 | $458.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $816.29 / $935.96 / $1,241.31
| Professional | TC | $816.29 | $935.96 | $1,241.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.70 / $1,229.33 / $2,458.67
| Professional | | $1,061.70 | $1,229.33 | $2,458.67 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $289.22 / $382.21 / $760.53
| Professional | 26 | $289.22 | $382.21 | $760.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $764.86 / $886.70 / $1,959.66
| Professional | TC | $764.86 | $886.70 | $1,959.66 |