- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $150.91 / $164.80 / $188.65
| Facility | 26 | $150.91 | $164.80 | $188.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.00 / $207.00 / $536.36
| Professional | 26 | $90.00 | $207.00 | $536.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $131.61 / $174.09 / $227.52
| Professional | 26 | $131.61 | $174.09 | $227.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $131.61 / $192.74 / $227.52
| Professional | 26 | $131.61 | $192.74 | $227.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $101.49 / $104.30 / $239.27
| Professional | 26 | $101.49 | $104.30 | $239.27 |