- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.24 / $1,175.74 / $1,819.77
| Professional | | $1,159.24 | $1,175.74 | $1,819.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $318.36 / $335.22 / $511.41
| Professional | 26 | $318.36 | $335.22 | $511.41 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $824.02 / $857.38 / $1,308.35
| Professional | TC | $824.02 | $857.38 | $1,308.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.00 / $2,182.51 / $3,800.25
| Professional | | $1,481.00 | $2,182.51 | $3,800.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $424.92 / $605.24 / $1,003.07
| Professional | 26 | $424.92 | $605.24 | $1,003.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $1,056.07 / $1,503.70 / $1,577.27
| Professional | TC | $1,056.07 | $1,503.70 | $1,577.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.00 / $2,060.39 / $3,800.25
| Professional | | $1,481.00 | $2,060.39 | $3,800.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $424.92 / $556.69 / $1,003.07
| Professional | 26 | $424.92 | $556.69 | $1,003.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $1,056.07 / $1,302.51 / $1,577.27
| Professional | TC | $1,056.07 | $1,302.51 | $1,577.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,442.74 / $1,572.58 / $4,664.39
| Professional | | $1,442.74 | $1,572.58 | $4,664.39 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $389.78 / $483.91 / $1,231.16
| Professional | 26 | $389.78 | $483.91 | $1,231.16 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $1,052.96 / $1,111.73 / $3,433.23
| Professional | TC | $1,052.96 | $1,111.73 | $3,433.23 |