- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $151.36 / $251.19 / $251.19
| Facility | 26 | $151.36 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $125.89 / $251.19
| Professional | 26 | $91.20 | $125.89 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $138.04 / $154.88
| Professional | 26 | $107.15 | $138.04 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $39.81 / $89.13 / $89.13
| Professional | 26 | $39.81 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $100.00 / $199.53
| Professional | 26 | $58.88 | $100.00 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $95.50 / $147.91
| Professional | 26 | $79.43 | $95.50 | $147.91 |