- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $90.56 / $90.56 / $90.56
| Facility | 26 | $90.56 | $90.56 | $90.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.80 / $135.80 / $136.47
| Professional | | $135.80 | $135.80 | $136.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $45.91 / $52.67 / $52.67
| Professional | TC | $45.91 | $52.67 | $52.67 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $106.07 / $106.07 / $106.07
| Facility | 26 | $106.07 | $106.07 | $106.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.84 / $184.88 / $853.85
| Professional | | $157.84 | $184.88 | $853.85 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $54.23 / $75.44 / $251.03
| Professional | TC | $54.23 | $75.44 | $251.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.44 / $191.09 / $394.62
| Professional | | $114.44 | $191.09 | $394.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $37.65 / $76.34 / $158.13
| Professional | TC | $37.65 | $76.34 | $158.13 |