- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Facility | 26 | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $338.84 / $407.38 / $912.01
| Professional | TC | $338.84 | $407.38 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $257.04 / $363.08 / $741.31
| Facility | 26 | $257.04 | $363.08 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $389.05 / $660.69 / $2,754.23
| Professional | TC | $389.05 | $660.69 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $416.87 / $724.44 / $1,412.54
| Professional | TC | $416.87 | $724.44 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $489.78 / $851.14 / $1,318.26
| Professional | TC | $489.78 | $851.14 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $257.04 / $363.08 / $741.31
| Facility | 26 | $257.04 | $363.08 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $389.05 / $676.08 / $2,754.23
| Professional | TC | $389.05 | $676.08 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $416.87 / $707.95 / $1,412.54
| Professional | TC | $416.87 | $707.95 | $1,412.54 |