- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $113.41 / $124.75 / $124.75
| Facility | 26 | $113.41 | $124.75 | $124.75 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $90.00 / $125.77 / $291.50
| Professional | 26 | $90.00 | $125.77 | $291.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $130.13 / $130.13 / $130.13
| Facility | 26 | $130.13 | $130.13 | $130.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $122.74 / $150.09 / $690.00
| Professional | 26 | $122.74 | $150.09 | $690.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $245.37 / $245.37 / $304.83
| Professional | 26 | $245.37 | $245.37 | $304.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $77.56 / $113.36 / $212.72
| Professional | 26 | $77.56 | $113.36 | $212.72 |