- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $69.19 / $69.19 / $87.17
| Facility | 26 | $69.19 | $69.19 | $87.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.19 / $90.00 / $291.50
| Professional | 26 | $69.19 | $90.00 | $291.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.06 / $67.06 / $67.06
| Professional | 26 | $67.06 | $67.06 | $67.06 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $108.65 / $108.65 / $108.65
| Professional | 26 | $108.65 | $108.65 | $108.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.47 / $81.81 / $154.19
| Professional | 26 | $50.47 | $81.81 | $154.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.05 / $58.05 / $72.64
| Facility | 26 | $58.05 | $58.05 | $72.64 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.05 / $69.19 / $164.97
| Professional | 26 | $58.05 | $69.19 | $164.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $64.20 / $76.38 / $111.50
| Professional | 26 | $64.20 | $76.38 | $111.50 |