- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $26.05 / $26.05 / $26.58
| Facility | 26 | $26.05 | $26.05 | $26.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.91 / $110.60 / $166.90
| Professional | | $100.91 | $110.60 | $166.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.00 / $547.00 / $547.00
| Professional | | $333.00 | $547.00 | $547.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.26 / $143.19 / $278.63
| Professional | | $98.26 | $143.19 | $278.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.65 / $227.42 / $338.81
| Professional | | $104.65 | $227.42 | $338.81 |