- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $125.89 / $125.89 / $125.89
| Facility | 26 | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $147.91 / $380.19
| Professional | 26 | $100.00 | $147.91 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.65 / $151.36 / $234.42
| Professional | 26 | $109.65 | $151.36 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $151.36 / $251.19
| Professional | 26 | $87.10 | $151.36 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $134.90 / $158.49 / $309.03
| Professional | 26 | $134.90 | $158.49 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.20 / $162.18 / $302.00
| Professional | 26 | $112.20 | $162.18 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $134.90 / $169.82 / $239.88
| Professional | 26 | $134.90 | $169.82 | $239.88 |