- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $126.91 / $126.91 / $126.91
| Facility | 26 | $126.91 | $126.91 | $126.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $366.91 / $392.42 / $394.13
| Professional | TC | $366.91 | $392.42 | $394.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $353.20 / $520.35 / $925.11
| Professional | TC | $353.20 | $520.35 | $925.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $438.57 / $524.44 / $740.66
| Professional | TC | $438.57 | $524.44 | $740.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $524.85 / $581.04 / $1,952.41
| Professional | TC | $524.85 | $581.04 | $1,952.41 |