- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Facility | 26 | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $100.00 / $154.88
| Professional | | $83.18 | $100.00 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $93.33 / $177.83
| Professional | | $70.79 | $93.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $128.82 / $223.87
| Professional | | $102.33 | $128.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $141.25 / $269.15
| Professional | | $100.00 | $141.25 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $107.15 / $190.55
| Professional | | $87.10 | $107.15 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $134.90 / $208.93
| Professional | | $97.72 | $134.90 | $208.93 |