- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $105.94 / $105.94 / $105.94
| Facility | 26 | $105.94 | $105.94 | $105.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $96.42 / $105.94 / $233.80
| Professional | 26 | $96.42 | $105.94 | $233.80 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $124.44 / $124.44 / $124.44
| Facility | 26 | $124.44 | $124.44 | $124.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.94 / $145.66 / $532.51
| Professional | 26 | $117.94 | $145.66 | $532.51 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $83.03 / $152.74 / $256.56
| Professional | 26 | $83.03 | $152.74 | $256.56 |