- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $165.98 / $295.75 / $671.50
| Facility | 26 | $165.98 | $295.75 | $671.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $320.35 / $425.17 / $821.12
| Professional | TC | $320.35 | $425.17 | $821.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $343.15 / $544.82 / $735.45
| Professional | TC | $343.15 | $544.82 | $735.45 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $487.06 / $650.91 / $1,313.96
| Professional | TC | $487.06 | $650.91 | $1,313.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $448.50 / $619.86 / $869.19
| Professional | TC | $448.50 | $619.86 | $869.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $411.67 / $612.24 / $1,300.92
| Professional | TC | $411.67 | $612.24 | $1,300.92 |