- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $109.65 / $144.54 / $269.15
| Facility | 26 | $109.65 | $144.54 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $338.84 / $416.87 / $616.60
| Professional | TC | $338.84 | $416.87 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $302.00 / $446.68 / $831.76
| Professional | TC | $302.00 | $446.68 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.18 / $151.36 / $407.38
| Facility | 26 | $28.18 | $151.36 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $380.19 / $588.84 / $1,318.26
| Professional | TC | $380.19 | $588.84 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $331.13 / $467.74 / $891.25
| Professional | TC | $331.13 | $467.74 | $891.25 |