- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.33 / $120.23 / $229.09
| Facility | 26 | $102.33 | $120.23 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $141.25 / $371.54
| Professional | | $91.20 | $141.25 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $30.90 / $51.29 / $134.90
| Professional | TC | $30.90 | $51.29 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $173.78 / $257.04
| Professional | | $114.82 | $173.78 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $42.66 / $60.26 / $120.23
| Professional | TC | $42.66 | $60.26 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $165.96 / $331.13
| Professional | | $107.15 | $165.96 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $40.74 / $58.88 / $120.23
| Professional | TC | $40.74 | $58.88 | $120.23 |