- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $77.62 / $112.20 / $112.20
| Facility | 26 | $77.62 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $138.04 / $302.00
| Professional | | $87.10 | $138.04 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $295.12 / $346.74
| Professional | | $208.93 | $295.12 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | 26 | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $165.96 / $281.84
| Professional | | $100.00 | $165.96 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $141.25 / $234.42
| Professional | | $107.15 | $141.25 | $234.42 |