- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $115.26 / $115.26 / $115.26
| Facility | 26 | $115.26 | $115.26 | $115.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $342.31 / $423.18 / $493.36
| Professional | TC | $342.31 | $423.18 | $493.36 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $132.76 / $132.76 / $132.76
| Facility | 26 | $132.76 | $132.76 | $132.76 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $353.76 / $474.38 / $1,390.98
| Professional | TC | $353.76 | $474.38 | $1,390.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $291.93 / $444.54 / $628.77
| Professional | TC | $291.93 | $444.54 | $628.77 |