- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $125.00 / $125.00 / $291.50
| Professional | 26 | $125.00 | $125.00 | $291.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $736.06 / $736.06 / $736.06
| Facility | 26 | $736.06 | $736.06 | $736.06 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $145.33 / $145.33 / $477.65
| Professional | 26 | $145.33 | $145.33 | $477.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $155.53 / $169.32 / $477.65
| Professional | 26 | $155.53 | $169.32 | $477.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $155.53 / $169.32 / $477.65
| Professional | 26 | $155.53 | $169.32 | $477.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $113.43 / $170.21 / $260.87
| Professional | 26 | $113.43 | $170.21 | $260.87 |