- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.12 / $89.13 / $181.97
| Facility | 26 | $25.12 | $89.13 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $100.00 / $190.55
| Professional | | $66.07 | $100.00 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $125.89 / $223.87
| Professional | | $87.10 | $125.89 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $114.82 / $436.52
| Professional | | $83.18 | $114.82 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $204.17 / $251.19
| Professional | | $114.82 | $204.17 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $29.51 / $58.88 / $63.10
| Professional | 26 | $29.51 | $58.88 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $100.00 / $281.84
| Professional | | $48.98 | $100.00 | $281.84 |