- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.54 / $120.54 / $120.54
| Facility | 26 | $120.54 | $120.54 | $120.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $342.31 / $411.52 / $535.71
| Professional | TC | $342.31 | $411.52 | $535.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $210.00 / $298.33 / $463.96
| Professional | TC | $210.00 | $298.33 | $463.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $379.19 / $466.36 / $798.89
| Professional | TC | $379.19 | $466.36 | $798.89 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $135.18 / $179.36 / $304.89
| Facility | 26 | $135.18 | $179.36 | $304.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $333.62 / $412.50 / $752.68
| Professional | TC | $333.62 | $412.50 | $752.68 |