- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $188.03 / $188.03 / $188.03
| Facility | 26 | $188.03 | $188.03 | $188.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $125.00 / $265.00
| Professional | 26 | $100.00 | $125.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.93 / $34.19 / $56.47
| Professional | 26 | $23.93 | $34.19 | $56.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $35.61 / $59.49 / $62.92
| Professional | 26 | $35.61 | $59.49 | $62.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.89 / $34.78 / $52.32
| Professional | 26 | $22.89 | $34.78 | $52.32 |