- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.08 / $28.08 / $28.08
| Facility | 26 | $28.08 | $28.08 | $28.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.60 / $92.44 / $104.48
| Professional | | $55.60 | $92.44 | $104.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.87 / $89.17 / $206.75
| Professional | | $31.87 | $89.17 | $206.75 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.78 / $32.78 / $32.78
| Facility | 26 | $32.78 | $32.78 | $32.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.61 / $107.00 / $227.13
| Professional | | $77.61 | $107.00 | $227.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.38 / $82.63 / $146.19
| Professional | | $51.38 | $82.63 | $146.19 |