- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $1,949.84
| Professional | | $1,096.48 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $288.40 / $537.03 / $1,230.27
| Professional | 26 | $288.40 | $537.03 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $794.33 / $933.25 / $1,412.54
| Professional | TC | $794.33 | $933.25 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,041.74 / $3,801.89
| Professional | | $1,479.11 | $2,041.74 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $426.58 / $562.34 / $1,000.00
| Professional | 26 | $426.58 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $1,047.13 / $1,288.25 / $1,584.89
| Professional | TC | $1,047.13 | $1,288.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,659.59 / $4,677.35
| Professional | | $1,445.44 | $1,659.59 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $389.05 / $467.74 / $1,202.26
| Professional | 26 | $389.05 | $467.74 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $1,047.13 / $1,122.02 / $3,235.94
| Professional | TC | $1,047.13 | $1,122.02 | $3,235.94 |