- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $45.24 / $59.47 / $59.47
| Facility | 26 | $45.24 | $59.47 | $59.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.84 / $204.84 / $204.84
| Professional | | $204.84 | $204.84 | $204.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $73.34 / $73.34 / $73.34
| Professional | 26 | $73.34 | $73.34 | $73.34 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $131.51 / $131.51 / $131.51
| Professional | TC | $131.51 | $131.51 | $131.51 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $47.22 / $47.22 / $50.79
| Professional | 26 | $47.22 | $47.22 | $50.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.78 / $202.19 / $278.67
| Professional | | $102.78 | $202.19 | $278.67 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $35.83 / $44.61 / $101.04
| Professional | 26 | $35.83 | $44.61 | $101.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $66.05 / $154.40 / $215.55
| Professional | TC | $66.05 | $154.40 | $215.55 |