- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.19 / $146.62 / $180.00
| Facility | 26 | $120.19 | $146.62 | $180.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $118.75 / $180.00 / $180.00
| Professional | 26 | $118.75 | $180.00 | $180.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $101.64 / $116.59 / $149.47
| Professional | 26 | $101.64 | $116.59 | $149.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.05 / $130.94 / $149.75
| Professional | 26 | $87.05 | $130.94 | $149.75 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $76.81 / $97.77 / $170.48
| Professional | 26 | $76.81 | $97.77 | $170.48 |