- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $691.50 / $691.50 / $691.50
| Facility | 26 | $691.50 | $691.50 | $691.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.58 / $104.21 / $116.91
| Professional | 26 | $75.58 | $104.21 | $116.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.29 / $128.99 / $212.42
| Professional | 26 | $90.29 | $128.99 | $212.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $134.36 / $219.98 / $295.17
| Professional | 26 | $134.36 | $219.98 | $295.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $105.54 / $144.31 / $192.42
| Professional | 26 | $105.54 | $144.31 | $192.42 |