- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $152.04 / $180.00 / $198.59
| Facility | 26 | $152.04 | $180.00 | $198.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $118.75 / $182.44 / $265.00
| Professional | 26 | $118.75 | $182.44 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $179.00 / $192.43 / $207.97
| Professional | 26 | $179.00 | $192.43 | $207.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $130.38 / $149.55 / $191.73
| Professional | 26 | $130.38 | $149.55 | $191.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $110.72 / $166.69 / $188.88
| Professional | 26 | $110.72 | $166.69 | $188.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $205.85 / $221.29 / $239.17
| Professional | 26 | $205.85 | $221.29 | $239.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $105.26 / $130.94 / $218.41
| Professional | 26 | $105.26 | $130.94 | $218.41 |