- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.54 / $53.54 / $54.60
| Facility | 26 | $53.54 | $53.54 | $54.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.97 / $138.80 / $147.07
| Professional | | $90.97 | $138.80 | $147.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $494.00 / $494.00
| Professional | | $300.00 | $494.00 | $494.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.04 / $184.26 / $335.62
| Professional | | $110.04 | $184.26 | $335.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.41 / $238.22 / $440.70
| Professional | | $127.41 | $238.22 | $440.70 |