- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $125.00 / $125.00 / $291.50
| Professional | 26 | $125.00 | $125.00 | $291.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $648.04 / $648.04 / $648.04
| Facility | 26 | $648.04 | $648.04 | $648.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $137.16 / $150.06 / $427.52
| Professional | 26 | $137.16 | $150.06 | $427.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $137.16 / $150.06 / $427.52
| Professional | 26 | $137.16 | $150.06 | $427.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $106.35 / $149.87 / $233.49
| Professional | 26 | $106.35 | $149.87 | $233.49 |