- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $125.89 / $302.00 / $724.44
| Facility | 26 | $125.89 | $302.00 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $251.19 / $416.87
| Professional | 26 | $114.82 | $251.19 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.20 / $128.82 / $162.18
| Professional | 26 | $112.20 | $128.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.50 / $194.98 / $549.54
| Professional | 26 | $95.50 | $194.98 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $131.83 / $245.47
| Professional | 26 | $114.82 | $131.83 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $144.54 / $371.54
| Professional | 26 | $85.11 | $144.54 | $371.54 |