- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $144.54 / $389.05
| Facility | 26 | $87.10 | $144.54 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $70.79 / $125.89 / $346.74
| Professional | 26 | $70.79 | $125.89 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $95.50 / $218.78
| Professional | 26 | $66.07 | $95.50 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $16.60 / $95.50 / $295.12
| Facility | 26 | $16.60 | $95.50 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $107.15 / $199.53
| Professional | 26 | $58.88 | $107.15 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $81.28 / $154.88
| Professional | 26 | $58.88 | $81.28 | $154.88 |