- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $70.09 / $126.19 / $150.22
| Facility | 26 | $70.09 | $126.19 | $150.22 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $70.09 / $101.48 / $200.00
| Professional | 26 | $70.09 | $101.48 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $158.18 / $158.18 / $158.18
| Professional | 26 | $158.18 | $158.18 | $158.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.73 / $117.16 / $162.01
| Professional | 26 | $69.73 | $117.16 | $162.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.34 / $69.90 / $122.86
| Professional | 26 | $58.34 | $69.90 | $122.86 |