- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $112.40 / $137.58 / $250.00
| Facility | 26 | $112.40 | $137.58 | $250.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.00 / $125.00 / $291.50
| Professional | 26 | $90.00 | $125.00 | $291.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $96.46 / $126.01 / $207.71
| Professional | 26 | $96.46 | $126.01 | $207.71 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $115.69 / $115.69 / $115.69
| Facility | 26 | $115.69 | $115.69 | $115.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $102.27 / $150.06 / $247.44
| Professional | 26 | $102.27 | $150.06 | $247.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $92.23 / $119.44 / $218.03
| Professional | 26 | $92.23 | $119.44 | $218.03 |