- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.63 / $125.00 / $265.00
| Professional | 26 | $93.63 | $125.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.45 / $114.42 / $183.14
| Professional | 26 | $91.45 | $114.42 | $183.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $108.98 / $144.44 / $196.45
| Professional | 26 | $108.98 | $144.44 | $196.45 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.23 / $126.38 / $237.12
| Professional | 26 | $109.23 | $126.38 | $237.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.63 / $125.00 / $153.57
| Professional | 26 | $93.63 | $125.00 | $153.57 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $110.31 / $138.81 / $177.69
| Professional | 26 | $110.31 | $138.81 | $177.69 |