- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $125.00 / $125.00 / $125.00
| Professional | 26 | $125.00 | $125.00 | $125.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $590.78 / $590.78 / $590.78
| Facility | 26 | $590.78 | $590.78 | $590.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $125.02 / $134.85 / $380.14
| Professional | 26 | $125.02 | $134.85 | $380.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $125.02 / $134.85 / $380.14
| Professional | 26 | $125.02 | $134.85 | $380.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.14 / $121.67 / $207.61
| Professional | 26 | $97.14 | $121.67 | $207.61 |