- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.90 / $50.21 / $92.68
| Facility | 26 | $30.90 | $50.21 | $92.68 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $50.00 / $51.50 / $53.00
| Facility | 26 | $50.00 | $51.50 | $53.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $14.37 / $23.06 / $52.49
| Professional | 26 | $14.37 | $23.06 | $52.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $51.50 / $100.00 / $100.00
| Facility | 26 | $51.50 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $51.50 / $53.00 / $87.06
| Facility | 26 | $51.50 | $53.00 | $87.06 |