- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $138.22 / $138.22 / $166.90
| Facility | 26 | $138.22 | $138.22 | $166.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $336.22 / $442.35 / $753.98
| Professional | TC | $336.22 | $442.35 | $753.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $390.74 / $496.14 / $628.66
| Professional | TC | $390.74 | $496.14 | $628.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $369.02 / $465.48 / $720.16
| Professional | TC | $369.02 | $465.48 | $720.16 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $307.67 / $399.60 / $715.70
| Professional | TC | $307.67 | $399.60 | $715.70 |