- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $54.65 / $54.65 / $54.65
| Facility | 26 | $54.65 | $54.65 | $54.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.77 / $96.69 / $144.93
| Professional | | $70.77 | $96.69 | $144.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.56 / $205.00 / $225.51
| Professional | | $168.56 | $205.00 | $225.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.61 / $190.25 / $293.19
| Professional | | $109.61 | $190.25 | $293.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.58 / $177.38 / $584.30
| Professional | | $107.58 | $177.38 | $584.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.89 / $184.17 / $246.97
| Professional | | $107.89 | $184.17 | $246.97 |