- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $34.00 / $37.40 / $37.40
| Facility | 26 | $34.00 | $37.40 | $37.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.63 / $214.74 / $237.41
| Professional | | $192.63 | $214.74 | $237.41 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $39.42 / $39.42 / $39.42
| Facility | 26 | $39.42 | $39.42 | $39.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.58 / $258.07 / $996.25
| Professional | | $177.58 | $258.07 | $996.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.13 / $192.74 / $341.57
| Professional | | $139.13 | $192.74 | $341.57 |