- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $130.88 / $250.00 / $250.00
| Facility | 26 | $130.88 | $250.00 | $250.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.00 / $250.00 / $265.00
| Professional | 26 | $90.00 | $250.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $145.19 / $170.78 / $226.77
| Professional | 26 | $145.19 | $170.78 | $226.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $103.81 / $103.81 / $103.81
| Professional | 26 | $103.81 | $103.81 | $103.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.59 / $115.07 / $246.37
| Professional | 26 | $74.59 | $115.07 | $246.37 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $101.49 / $134.22 / $265.52
| Professional | 26 | $101.49 | $134.22 | $265.52 |