- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $71.40 / $71.41 / $104.93
| Facility | 26 | $71.40 | $71.41 | $104.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $71.41 / $90.00 / $291.50
| Professional | 26 | $71.41 | $90.00 | $291.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.95 / $83.95 / $83.95
| Professional | 26 | $83.95 | $83.95 | $83.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $108.54 / $155.06 / $170.57
| Professional | 26 | $108.54 | $155.06 | $170.57 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $116.94 / $175.94 / $683.27
| Professional | 26 | $116.94 | $175.94 | $683.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.57 / $116.57 / $170.86
| Professional | 26 | $89.57 | $116.57 | $170.86 |