- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $91.71 / $91.72 / $91.72
| Facility | 26 | $91.71 | $91.72 | $91.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.67 / $138.53 / $173.46
| Professional | | $105.67 | $138.53 | $173.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.43 / $191.00 / $225.38
| Professional | | $139.43 | $191.00 | $225.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.79 / $58.79 / $59.30
| Facility | 26 | $58.79 | $58.79 | $59.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.39 / $150.28 / $319.68
| Professional | | $101.39 | $150.28 | $319.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.79 / $122.06 / $189.94
| Professional | | $93.79 | $122.06 | $189.94 |