- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $642.74 / $642.74 / $642.74
| Facility | 26 | $642.74 | $642.74 | $642.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $103.49 / $125.00
| Professional | 26 | $100.00 | $103.49 | $125.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.62 / $119.46 / $201.65
| Professional | 26 | $83.62 | $119.46 | $201.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $124.44 / $213.51 / $215.06
| Professional | 26 | $124.44 | $213.51 | $215.06 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $78.25 / $99.08 / $178.85
| Professional | 26 | $78.25 | $99.08 | $178.85 |