- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $47.86 / $61.66 / $131.83
| Facility | 26 | $47.86 | $61.66 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $97.72 / $218.78
| Professional | | $83.18 | $97.72 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $100.00 / $181.97
| Professional | | $70.79 | $100.00 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $12.59 / $67.61 / $181.97
| Facility | 26 | $12.59 | $67.61 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $138.04 / $281.84
| Professional | | $91.20 | $138.04 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $117.49 / $208.93
| Professional | | $81.28 | $117.49 | $208.93 |