- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $112.20 / $181.97
| Facility | 26 | $91.20 | $112.20 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $70.79 / $158.49 / $263.03
| Professional | 26 | $70.79 | $158.49 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $67.61 / $67.61
| Professional | 26 | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $91.20 / $114.82
| Professional | 26 | $79.43 | $91.20 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $104.71 / $120.23
| Professional | 26 | $66.07 | $104.71 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $79.43 / $131.83
| Professional | 26 | $63.10 | $79.43 | $131.83 |