- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $34.50 / $100.00 / $100.00
| Facility | 26 | $34.50 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $40.43 / $100.00 / $265.00
| Professional | 26 | $40.43 | $100.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $21.56 / $21.56 / $28.68
| Professional | 26 | $21.56 | $21.56 | $28.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.37 / $29.22 / $40.32
| Professional | 26 | $23.37 | $29.22 | $40.32 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.09 / $38.61 / $62.28
| Professional | 26 | $33.09 | $38.61 | $62.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $26.26 / $33.61 / $58.12
| Professional | 26 | $26.26 | $33.61 | $58.12 |