- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.31 / $66.31 / $66.31
| Facility | 26 | $66.31 | $66.31 | $66.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.34 / $132.82 / $207.31
| Professional | | $108.34 | $132.82 | $207.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.07 / $177.73 / $246.90
| Professional | | $122.07 | $177.73 | $246.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.75 / $180.02 / $323.37
| Professional | | $85.75 | $180.02 | $323.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.38 / $162.31 / $274.36
| Professional | | $131.38 | $162.31 | $274.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.70 / $132.82 / $155.88
| Professional | | $104.70 | $132.82 | $155.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.82 / $196.00 / $306.64
| Professional | | $143.82 | $196.00 | $306.64 |