- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $116.90 / $210.42 / $250.50
| Facility | 26 | $116.90 | $210.42 | $250.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.00 / $200.00 / $330.75
| Professional | 26 | $90.00 | $200.00 | $330.75 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $262.80 / $262.80 / $262.80
| Professional | 26 | $262.80 | $262.80 | $262.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $116.78 / $196.69 / $271.52
| Professional | 26 | $116.78 | $196.69 | $271.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $98.22 / $127.16 / $206.91
| Professional | 26 | $98.22 | $127.16 | $206.91 |