- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $125.89 / $154.88
| Facility | 26 | $91.20 | $125.89 | $154.88 |
- 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
- $158.49 / $208.93 / $229.09
| Professional | 26 | $158.49 | $208.93 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $169.82 / $223.87
| Professional | 26 | $114.82 | $169.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $186.21 / $1,479.11
| Professional | 26 | $91.20 | $186.21 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $177.83 / $245.47
| Professional | 26 | $91.20 | $177.83 | $245.47 |