- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $115.09 / $115.09 / $131.21
| Facility | 26 | $115.09 | $115.09 | $131.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $342.31 / $399.46 / $578.36
| Professional | TC | $342.31 | $399.46 | $578.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $257.58 / $303.04 / $508.67
| Professional | TC | $257.58 | $303.04 | $508.67 |
- 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
- $345.10 / $486.89 / $688.09
| Professional | TC | $345.10 | $486.89 | $688.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $317.07 / $443.66 / $744.05
| Professional | TC | $317.07 | $443.66 | $744.05 |