- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $125.89 / $125.89 / $125.89
| Facility | 26 | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $338.84 / $426.58 / $741.31
| Professional | TC | $338.84 | $426.58 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $354.81 / $501.19 / $812.83
| Professional | TC | $354.81 | $501.19 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $407.38 / $588.84 / $1,000.00
| Professional | TC | $407.38 | $588.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $501.19 / $707.95 / $1,348.96
| Professional | TC | $501.19 | $707.95 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $346.74 / $446.68 / $912.01
| Professional | TC | $346.74 | $446.68 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $371.54 / $588.84 / $1,023.29
| Professional | TC | $371.54 | $588.84 | $1,023.29 |