- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $98.93 / $113.81 / $2,887.46
| Facility | 26 | $98.93 | $113.81 | $2,887.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.22 / $171.52 / $219.79
| Professional | | $151.22 | $171.52 | $219.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.69 / $162.00 / $221.69
| Professional | | $137.69 | $162.00 | $221.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.53 / $100.79 / $191.33
| Professional | | $70.53 | $100.79 | $191.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.91 / $102.91 / $102.91
| Facility | 26 | $102.91 | $102.91 | $102.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.47 / $217.18 / $357.12
| Professional | | $167.47 | $217.18 | $357.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.79 / $171.44 / $305.70
| Professional | | $134.79 | $171.44 | $305.70 |