- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $42.81 / $42.81 / $42.81
| Facility | 26 | $42.81 | $42.81 | $42.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.81 / $63.21 / $291.50
| Professional | 26 | $42.81 | $63.21 | $291.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $59.61 / $85.16 / $93.68
| Professional | 26 | $59.61 | $85.16 | $93.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.54 / $104.94 / $540.77
| Professional | 26 | $69.54 | $104.94 | $540.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.20 / $69.86 / $99.13
| Professional | 26 | $54.20 | $69.86 | $99.13 |