- 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
- Facility
- Modifier
- 26
- Low / Median / High Price
- $575.87 / $575.87 / $575.87
| Facility | 26 | $575.87 | $575.87 | $575.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $116.60 / $125.11 / $351.33
| Professional | 26 | $116.60 | $125.11 | $351.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $116.60 / $125.11 / $351.33
| Professional | 26 | $116.60 | $125.11 | $351.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.67 / $123.27 / $191.88
| Professional | 26 | $95.67 | $123.27 | $191.88 |