- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $88.47 / $100.00 / $100.00
| Facility | 26 | $88.47 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.63 / $137.41 / $265.00
| Professional | 26 | $93.63 | $137.41 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.68 / $125.77 / $183.68
| Professional | 26 | $93.68 | $125.77 | $183.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $86.19 / $120.41 / $221.37
| Professional | 26 | $86.19 | $120.41 | $221.37 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $88.47 / $139.78 / $335.68
| Professional | 26 | $88.47 | $139.78 | $335.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $84.20 / $145.61 / $238.20
| Professional | 26 | $84.20 | $145.61 | $238.20 |