- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $115.58 / $208.04 / $247.66
| Facility | 26 | $115.58 | $208.04 | $247.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.00 / $167.31 / $291.50
| Professional | 26 | $90.00 | $167.31 | $291.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.57 / $260.58 / $260.58
| Professional | 26 | $112.57 | $260.58 | $260.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $115.25 / $194.68 / $268.99
| Professional | 26 | $115.25 | $194.68 | $268.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.24 / $120.78 / $202.36
| Professional | 26 | $97.24 | $120.78 | $202.36 |