- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $144.34 / $144.34 / $144.34
| Facility | 26 | $144.34 | $144.34 | $144.34 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $336.22 / $411.52 / $492.52
| Professional | TC | $336.22 | $411.52 | $492.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $284.14 / $389.23 / $459.29
| Professional | TC | $284.14 | $389.23 | $459.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $317.54 / $395.08 / $1,280.06
| Professional | TC | $317.54 | $395.08 | $1,280.06 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $301.13 / $366.39 / $578.90
| Professional | TC | $301.13 | $366.39 | $578.90 |