- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $171.01 / $171.01 / $171.01
| Facility | 26 | $171.01 | $171.01 | $171.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.67 / $109.55 / $129.54
| Professional | | $84.67 | $109.55 | $129.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.05 / $164.41 / $227.22
| Professional | | $154.05 | $164.41 | $227.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.57 / $209.43 / $258.20
| Professional | | $107.57 | $209.43 | $258.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.00 / $138.94 / $249.86
| Professional | | $83.00 | $138.94 | $249.86 |