- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $190.55 / $251.19 / $269.15
| Facility | 26 | $190.55 | $251.19 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $190.55 / $354.81
| Professional | 26 | $114.82 | $190.55 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $85.11 / $263.03
| Professional | 26 | $85.11 | $85.11 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $131.83 / $169.82 / $190.55
| Professional | 26 | $131.83 | $169.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $39.81 / $112.20 / $112.20
| Professional | 26 | $39.81 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.13 / $125.89 / $245.47
| Professional | 26 | $74.13 | $125.89 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $120.23 / $186.21
| Professional | 26 | $100.00 | $120.23 | $186.21 |