- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $15.85 / $52.48 / $117.49
| Facility | 26 | $15.85 | $52.48 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $91.20 / $257.04
| Professional | | $58.88 | $91.20 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.89 / $100.00 / $275.42
| Professional | | $20.89 | $100.00 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $89.13 / $263.03
| Professional | | $69.18 | $89.13 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $104.71 / $223.87
| Professional | | $95.50 | $104.71 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $18.20 / $19.50 / $39.81
| Professional | 26 | $18.20 | $19.50 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $109.65 / $281.84
| Professional | | $63.10 | $109.65 | $281.84 |