- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $139.88
| Facility | 26 | $100.00 | $100.00 | $139.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $124.16
| Professional | 26 | $100.00 | $100.00 | $124.16 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $82.77 / $93.02 / $132.08
| Professional | 26 | $82.77 | $93.02 | $132.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $103.38 / $123.67 / $220.82
| Professional | 26 | $103.38 | $123.67 | $220.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $82.55 / $98.14 / $176.08
| Professional | 26 | $82.55 | $98.14 | $176.08 |