- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $61.66 / $75.86 / $75.86
| Facility | 26 | $61.66 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $97.72 / $190.55
| Professional | | $79.43 | $97.72 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $104.71 / $114.82
| Professional | | $89.13 | $104.71 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $114.82 / $177.83
| Professional | | $83.18 | $114.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $100.00 / $173.78
| Professional | | $79.43 | $100.00 | $173.78 |