- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $26.00 / $26.00 / $26.51
| Facility | 26 | $26.00 | $26.00 | $26.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.65 / $113.62 / $166.63
| Professional | | $103.65 | $113.62 | $166.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.00 / $573.00 / $573.00
| Professional | | $348.00 | $573.00 | $573.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.86 / $149.87 / $301.44
| Professional | | $101.86 | $149.87 | $301.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.74 / $220.72 / $355.29
| Professional | | $109.74 | $220.72 | $355.29 |