- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $561.49 / $561.49 / $561.49
| Facility | 26 | $561.49 | $561.49 | $561.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $125.00
| Professional | 26 | $100.00 | $100.00 | $125.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $73.67 / $105.24 / $174.13
| Professional | 26 | $73.67 | $105.24 | $174.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.62 / $185.47 / $187.89
| Professional | 26 | $109.62 | $185.47 | $187.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $68.36 / $86.40 / $156.24
| Professional | 26 | $68.36 | $86.40 | $156.24 |