- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $125.00 / $125.00 / $291.50
| Professional | 26 | $125.00 | $125.00 | $291.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $37.58 / $37.58 / $37.58
| Professional | 26 | $37.58 | $37.58 | $37.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $40.35 / $43.08 / $121.88
| Professional | 26 | $40.35 | $43.08 | $121.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $40.35 / $43.08 / $121.88
| Professional | 26 | $40.35 | $43.08 | $121.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $29.67 / $44.13 / $66.56
| Professional | 26 | $29.67 | $44.13 | $66.56 |