- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $125.89 / $218.78 / $467.74
| Facility | 26 | $125.89 | $218.78 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.65 / $125.89 / $363.08
| Professional | 26 | $109.65 | $125.89 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $169.82 / $363.08
| Professional | 26 | $89.13 | $169.82 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.20 / $234.42 / $338.84
| Professional | 26 | $112.20 | $234.42 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $144.54 / $257.04 / $338.84
| Professional | 26 | $144.54 | $257.04 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $123.03 / $213.80 / $346.74
| Professional | 26 | $123.03 | $213.80 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.20 / $151.36 / $302.00
| Professional | 26 | $112.20 | $151.36 | $302.00 |