- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.81 / $30.81 / $30.81
| Facility | 26 | $30.81 | $30.81 | $30.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.69 / $233.73 / $233.73
| Professional | | $159.69 | $233.73 | $233.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.60 / $183.71 / $202.08
| Professional | | $128.60 | $183.71 | $202.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.77 / $265.91 / $1,051.18
| Professional | | $193.77 | $265.91 | $1,051.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.41 / $172.25 / $235.47
| Professional | | $122.41 | $172.25 | $235.47 |