- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $173.78 / $371.54 / $371.54
| Facility | 26 | $173.78 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $199.53 / $371.54
| Professional | 26 | $114.82 | $199.53 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $120.23 / $190.55
| Professional | 26 | $85.11 | $120.23 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $114.82 / $151.36
| Professional | 26 | $100.00 | $114.82 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $131.83 / $162.18 / $295.12
| Professional | 26 | $131.83 | $162.18 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $134.90 / $229.09
| Professional | 26 | $107.15 | $134.90 | $229.09 |