- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $22.23 / $22.23 / $37.75
| Facility | 26 | $22.23 | $22.23 | $37.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.64 / $125.06 / $188.28
| Professional | | $105.64 | $125.06 | $188.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.40 / $100.00 / $174.19
| Professional | | $76.40 | $100.00 | $174.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.74 / $107.02 / $162.03
| Professional | | $23.74 | $107.02 | $162.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $27.06 / $27.06 / $27.06
| Facility | 26 | $27.06 | $27.06 | $27.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.48 / $109.77 / $219.53
| Professional | | $69.48 | $109.77 | $219.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.12 / $128.13 / $274.18
| Professional | | $65.12 | $128.13 | $274.18 |