- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.54 / $126.25 / $142.50
| Facility | 26 | $120.54 | $126.25 | $142.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $342.31 / $411.52 / $611.38
| Professional | TC | $342.31 | $411.52 | $611.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $343.15 / $471.35 / $791.30
| Professional | TC | $343.15 | $471.35 | $791.30 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $132.76 / $132.76 / $132.76
| Facility | 26 | $132.76 | $132.76 | $132.76 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $384.50 / $568.40 / $985.87
| Professional | TC | $384.50 | $568.40 | $985.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $354.22 / $494.55 / $910.47
| Professional | TC | $354.22 | $494.55 | $910.47 |