- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $261.83 / $261.83 / $261.83
| Facility | 26 | $261.83 | $261.83 | $261.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.00 / $250.00 / $266.14
| Professional | 26 | $90.00 | $250.00 | $266.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $84.57 / $94.52 / $206.68
| Professional | 26 | $84.57 | $94.52 | $206.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $160.63 / $170.38 / $194.72
| Professional | 26 | $160.63 | $170.38 | $194.72 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,871.86 / $2,871.86 / $2,871.86
| Facility | 26 | $2,871.86 | $2,871.86 | $2,871.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $192.41 / $204.82 / $249.33
| Professional | 26 | $192.41 | $204.82 | $249.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $86.90 / $114.38 / $204.68
| Professional | 26 | $86.90 | $114.38 | $204.68 |