- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $17.45 / $18.25 / $109.10
| Facility | 26 | $17.45 | $18.25 | $109.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.62 / $161.40 / $285.39
| Professional | | $152.62 | $161.40 | $285.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.28 / $215.22 / $371.30
| Professional | | $149.28 | $215.22 | $371.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.01 / $251.72 / $425.51
| Professional | | $143.01 | $251.72 | $425.51 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $47.93 / $100.00 / $100.00
| Facility | 26 | $47.93 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.18 / $1,169.18 / $1,481.40
| Professional | | $1,169.18 | $1,169.18 | $1,481.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.22 / $212.89 / $450.48
| Professional | | $120.22 | $212.89 | $450.48 |