- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $111.68 / $111.68 / $111.69
| Facility | 26 | $111.68 | $111.68 | $111.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $102.84 / $111.69 / $371.37
| Professional | 26 | $102.84 | $111.69 | $371.37 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $116.05 / $153.57 / $246.35
| Professional | 26 | $116.05 | $153.57 | $246.35 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $105.68 / $157.22 / $264.11
| Professional | 26 | $105.68 | $157.22 | $264.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $111.70 / $168.08 / $210.63
| Professional | 26 | $111.70 | $168.08 | $210.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $102.39 / $187.09 / $292.33
| Professional | 26 | $102.39 | $187.09 | $292.33 |