- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $125.00 / $125.00 / $125.00
| Facility | 26 | $125.00 | $125.00 | $125.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.00 / $125.00 / $265.00
| Professional | 26 | $90.00 | $125.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.53 / $145.52 / $232.90
| Professional | 26 | $117.53 | $145.52 | $232.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $136.58 / $184.95 / $248.57
| Professional | 26 | $136.58 | $184.95 | $248.57 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $138.91 / $160.72 / $301.55
| Professional | 26 | $138.91 | $160.72 | $301.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.63 / $125.00 / $265.00
| Professional | 26 | $93.63 | $125.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $138.91 / $169.31 / $224.20
| Professional | 26 | $138.91 | $169.31 | $224.20 |