- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $157.50
| Facility | 26 | $100.00 | $100.00 | $157.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $265.00
| Professional | 26 | $100.00 | $100.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.94 / $79.93 / $138.60
| Professional | 26 | $67.94 | $79.93 | $138.60 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $78.58 / $78.58 / $78.58
| Facility | 26 | $78.58 | $78.58 | $78.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $68.98 / $117.33 / $330.51
| Professional | 26 | $68.98 | $117.33 | $330.51 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $66.42 / $75.53 / $106.14
| Professional | 26 | $66.42 | $75.53 | $106.14 |