- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $131.83 / $181.97 / $446.68
| Facility | 26 | $131.83 | $181.97 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,230.27
| Professional | | $562.34 | $794.33 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $134.90 / $213.80
| Professional | 26 | $97.72 | $134.90 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $467.74 / $645.65 / $1,023.29
| Professional | TC | $467.74 | $645.65 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $295.12 / $489.78
| Professional | | $223.87 | $295.12 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.66 / $56.23 / $93.33
| Professional | 26 | $42.66 | $56.23 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $181.97 / $239.88 / $407.38
| Professional | TC | $181.97 | $239.88 | $407.38 |