- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $57.54 / $57.54
| Facility | 26 | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $100.00 / $173.78
| Professional | | $83.18 | $100.00 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $331.13
| Professional | | $223.87 | $223.87 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $131.83 / $218.78
| Professional | | $117.49 | $131.83 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $131.83 / $331.13
| Professional | | $112.20 | $131.83 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $144.54 / $398.11
| Professional | | $125.89 | $144.54 | $398.11 |