- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $112.20 / $147.91
| Facility | 26 | $81.28 | $112.20 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $70.79 / $100.00 / $177.83
| Professional | 26 | $70.79 | $100.00 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $97.72 / $97.72
| Professional | 26 | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $77.62 / $190.55 / $295.12
| Professional | 26 | $77.62 | $190.55 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $93.33 / $177.83
| Professional | 26 | $79.43 | $93.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $64.57 / $75.86 / $134.90
| Professional | 26 | $64.57 | $75.86 | $134.90 |