- 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
- $439.15 / $439.15 / $439.15
| Facility | 26 | $439.15 | $439.15 | $439.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $94.90 / $94.90 / $288.30
| Professional | 26 | $94.90 | $94.90 | $288.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $92.30 / $102.14 / $288.30
| Professional | 26 | $92.30 | $102.14 | $288.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $92.30 / $102.14 / $288.30
| Professional | 26 | $92.30 | $102.14 | $288.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $71.75 / $100.68 / $157.44
| Professional | 26 | $71.75 | $100.68 | $157.44 |