- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $726.05 / $726.05 / $726.05
| Facility | 26 | $726.05 | $726.05 | $726.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $125.00 / $265.00
| Professional | 26 | $100.00 | $125.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $94.23 / $134.62 / $223.95
| Professional | 26 | $94.23 | $134.62 | $223.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $140.22 / $237.86 / $242.94
| Professional | 26 | $140.22 | $237.86 | $242.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $88.39 / $137.29 / $202.04
| Professional | 26 | $88.39 | $137.29 | $202.04 |