- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $21.86 / $28.00 / $52.27
| Facility | 26 | $21.86 | $28.00 | $52.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.12 / $199.53 / $268.77
| Professional | | $168.12 | $199.53 | $268.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.63 / $240.74 / $397.69
| Professional | | $149.63 | $240.74 | $397.69 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $44.30 / $51.04 / $60.60
| Facility | 26 | $44.30 | $51.04 | $60.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.28 / $251.61 / $440.76
| Professional | | $151.28 | $251.61 | $440.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.91 / $221.95 / $407.92
| Professional | | $151.91 | $221.95 | $407.92 |