- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.63 / $120.47 / $120.47
| Facility | 26 | $102.63 | $120.47 | $120.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.53 / $141.07 / $141.07
| Professional | | $121.53 | $141.07 | $141.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $42.83 / $51.58 / $51.58
| Professional | TC | $42.83 | $51.58 | $51.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.21 / $175.31 / $237.60
| Professional | | $115.21 | $175.31 | $237.60 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $43.54 / $60.41 / $96.06
| Professional | TC | $43.54 | $60.41 | $96.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.10 / $212.43 / $334.85
| Professional | | $122.10 | $212.43 | $334.85 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $44.44 / $78.65 / $124.86
| Professional | TC | $44.44 | $78.65 | $124.86 |