- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $125.00 / $130.40 / $291.50
| Professional | 26 | $125.00 | $130.40 | $291.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $719.12 / $719.12 / $719.12
| Facility | 26 | $719.12 | $719.12 | $719.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $142.84 / $142.84 / $474.14
| Professional | 26 | $142.84 | $142.84 | $474.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $152.05 / $167.81 / $474.14
| Professional | 26 | $152.05 | $167.81 | $474.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $152.05 / $167.81 / $474.14
| Professional | 26 | $152.05 | $167.81 | $474.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.26 / $165.82 / $258.95
| Professional | 26 | $117.26 | $165.82 | $258.95 |