- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $50.50 / $50.50 / $51.28
| Facility | 26 | $50.50 | $50.50 | $51.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.84 / $100.64 / $243.91
| Professional | | $92.84 | $100.64 | $243.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.00 / $506.00 / $506.00
| Professional | | $308.00 | $506.00 | $506.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.53 / $254.30 / $424.25
| Professional | | $183.53 | $254.30 | $424.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.52 / $240.94 / $697.39
| Professional | | $205.52 | $240.94 | $697.39 |