- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $45.71 / $45.71 / $53.70
| Facility | 26 | $45.71 | $45.71 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $109.65 / $186.21
| Professional | | $87.10 | $109.65 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $52.48 / $69.18 / $117.49
| Professional | TC | $52.48 | $69.18 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $147.91 / $251.19
| Professional | | $81.28 | $147.91 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $53.70 / $89.13 / $190.55
| Professional | TC | $53.70 | $89.13 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $138.04 / $245.47
| Professional | | $85.11 | $138.04 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $51.29 / $89.13 / $177.83
| Professional | TC | $51.29 | $89.13 | $177.83 |