- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $110.13 / $110.13 / $110.13
| Facility | 26 | $110.13 | $110.13 | $110.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $336.22 / $383.87 / $444.26
| Professional | TC | $336.22 | $383.87 | $444.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $333.64 / $475.08 / $577.91
| Professional | TC | $333.64 | $475.08 | $577.91 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $269.57 / $526.83 / $526.83
| Facility | 26 | $269.57 | $526.83 | $526.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $348.48 / $441.23 / $2,779.03
| Professional | TC | $348.48 | $441.23 | $2,779.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $342.37 / $429.66 / $739.53
| Professional | TC | $342.37 | $429.66 | $739.53 |