- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $152.24 / $152.24 / $228.36
| Facility | 26 | $152.24 | $152.24 | $228.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $348.98 / $450.08 / $755.37
| Professional | TC | $348.98 | $450.08 | $755.37 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $391.96 / $518.77 / $518.77
| Professional | TC | $391.96 | $518.77 | $518.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $332.27 / $511.07 / $761.04
| Professional | TC | $332.27 | $511.07 | $761.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $324.66 / $419.41 / $753.40
| Professional | TC | $324.66 | $419.41 | $753.40 |