- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $158.71
| Facility | 26 | $100.00 | $100.00 | $158.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $265.00
| Professional | 26 | $100.00 | $100.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.69 / $112.69 / $112.69
| Professional | 26 | $112.69 | $112.69 | $112.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.91 / $105.34 / $149.58
| Professional | 26 | $93.91 | $105.34 | $149.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.82 / $141.01 / $250.96
| Professional | 26 | $117.82 | $141.01 | $250.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.15 / $112.96 / $216.65
| Professional | 26 | $95.15 | $112.96 | $216.65 |