- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $165.96 / $389.05
| Facility | 26 | $117.49 | $165.96 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $234.42 / $426.58
| Professional | | $181.97 | $234.42 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.18 / $104.71 / $154.88
| Professional | 26 | $69.18 | $104.71 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $117.49 / $181.97 / $309.03
| Professional | TC | $117.49 | $181.97 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $154.88 / $275.42
| Professional | | $104.71 | $154.88 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $47.86 / $91.20
| Professional | 26 | $34.67 | $47.86 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $66.07 / $104.71 / $190.55
| Professional | TC | $66.07 | $104.71 | $190.55 |