- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.16 / $187.49 / $223.21
| Facility | 26 | $104.16 | $187.49 | $223.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.00 / $150.79 / $223.21
| Professional | 26 | $90.00 | $150.79 | $223.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $233.03 / $233.03 / $233.03
| Professional | 26 | $233.03 | $233.03 | $233.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $103.01 / $176.61 / $240.69
| Professional | 26 | $103.01 | $176.61 | $240.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.85 / $106.35 / $182.89
| Professional | 26 | $87.85 | $106.35 | $182.89 |