- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $47.86 / $117.49 / $131.83
| Facility | 26 | $47.86 | $117.49 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $100.00 / $218.78
| Professional | | $83.18 | $100.00 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $89.13 / $245.47
| Professional | | $43.65 | $89.13 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $141.25 / $380.19
| Professional | | $107.15 | $141.25 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $117.49 / $208.93
| Professional | | $102.33 | $117.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $64.57 / $114.82
| Professional | 26 | $56.23 | $64.57 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $154.88 / $263.03
| Professional | | $75.86 | $154.88 | $263.03 |