- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $19.30 / $19.30 / $19.64
| Facility | 26 | $19.30 | $19.30 | $19.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.52 / $169.52 / $186.89
| Professional | | $169.52 | $169.52 | $186.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.00 / $457.00 / $752.00
| Professional | | $457.00 | $457.00 | $752.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.40 / $254.40 / $518.45
| Professional | | $254.40 | $254.40 | $518.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.28 / $327.60 / $591.15
| Professional | | $160.28 | $327.60 | $591.15 |