- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.46 / $52.46 / $52.46
| Facility | 26 | $52.46 | $52.46 | $52.46 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.46 / $76.56 / $291.50
| Professional | 26 | $52.46 | $76.56 | $291.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.41 / $80.41 / $156.81
| Professional | 26 | $80.41 | $80.41 | $156.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $66.20 / $94.57 / $104.03
| Professional | 26 | $66.20 | $94.57 | $104.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $86.81 / $131.18 / $507.51
| Professional | 26 | $86.81 | $131.18 | $507.51 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $64.81 / $85.74 / $127.35
| Professional | 26 | $64.81 | $85.74 | $127.35 |