- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $55.88 / $55.88 / $55.88
| Facility | 26 | $55.88 | $55.88 | $55.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $55.88 / $55.88 / $91.36
| Professional | 26 | $55.88 | $55.88 | $91.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $76.16 / $108.80 / $119.68
| Professional | 26 | $76.16 | $108.80 | $119.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.21 / $136.33 / $531.70
| Professional | 26 | $91.21 | $136.33 | $531.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $70.09 / $91.59 / $128.36
| Professional | 26 | $70.09 | $91.59 | $128.36 |