- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $433.49 / $433.49 / $433.49
| Facility | 26 | $433.49 | $433.49 | $433.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $125.00 / $265.00
| Professional | 26 | $100.00 | $125.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.76 / $81.08 / $133.13
| Professional | 26 | $56.76 | $81.08 | $133.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $84.47 / $140.44 / $145.05
| Professional | 26 | $84.47 | $140.44 | $145.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.77 / $66.55 / $120.63
| Professional | 26 | $52.77 | $66.55 | $120.63 |