- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $142.19 / $142.19 / $142.19
| Facility | 26 | $142.19 | $142.19 | $142.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $342.31 / $401.04 / $555.83
| Professional | TC | $342.31 | $401.04 | $555.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $307.02 / $438.61 / $438.61
| Professional | TC | $307.02 | $438.61 | $438.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $432.29 / $603.17 / $1,014.73
| Professional | TC | $432.29 | $603.17 | $1,014.73 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $389.35 / $454.24 / $692.18
| Professional | TC | $389.35 | $454.24 | $692.18 |