- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $95.62 / $150.24 / $247.20
| Facility | 26 | $95.62 | $150.24 | $247.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.62 / $108.38 / $355.94
| Professional | 26 | $95.62 | $108.38 | $355.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $140.85 / $140.85 / $140.85
| Professional | 26 | $140.85 | $140.85 | $140.85 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $113.85 / $141.34 / $224.39
| Professional | 26 | $113.85 | $141.34 | $224.39 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $99.33 / $160.97 / $235.95
| Professional | 26 | $99.33 | $160.97 | $235.95 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $259.18 / $505.23 / $505.23
| Facility | 26 | $259.18 | $505.23 | $505.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $115.78 / $160.47 / $680.84
| Professional | 26 | $115.78 | $160.47 | $680.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $110.56 / $145.96 / $371.62
| Professional | 26 | $110.56 | $145.96 | $371.62 |