- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $9.16 / $10.63 / $10.63
| Professional | 26 | $9.16 | $10.63 | $10.63 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $15.02 / $15.80 / $15.80
| Professional | TC | $15.02 | $15.80 | $15.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $35.00 / $44.00 / $44.00
| Professional | 26 | $35.00 | $44.00 | $44.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.88 / $36.22 / $52.47
| Professional | 26 | $28.88 | $36.22 | $52.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $42.56 / $54.17 / $77.56
| Professional | TC | $42.56 | $54.17 | $77.56 |