- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.72 / $57.72 / $57.72
| Facility | 26 | $57.72 | $57.72 | $57.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.00 / $105.24 / $153.94
| Professional | | $97.00 | $105.24 | $153.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.08 / $158.08 / $274.60
| Professional | | $110.08 | $158.08 | $274.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $66.69 / $100.72
| Professional | | $32.34 | $66.69 | $100.72 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $203.75 / $203.75 / $203.75
| Facility | 26 | $203.75 | $203.75 | $203.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.91 / $183.87 / $245.80
| Professional | | $128.91 | $183.87 | $245.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.44 / $134.97 / $187.00
| Professional | | $90.44 | $134.97 | $187.00 |