- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $563.55 / $563.55 / $563.55
| Facility | 26 | $563.55 | $563.55 | $563.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.13 / $125.00
| Professional | 26 | $100.00 | $100.13 | $125.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.05 / $107.21 / $183.09
| Professional | 26 | $75.05 | $107.21 | $183.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $111.68 / $188.15 / $193.08
| Professional | 26 | $111.68 | $188.15 | $193.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $68.61 / $117.49 / $156.82
| Professional | 26 | $68.61 | $117.49 | $156.82 |