- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | 26 | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $97.72 / $213.80
| Professional | | $61.66 | $97.72 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $151.36 / $213.80
| Professional | | $104.71 | $151.36 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $151.36 / $309.03
| Professional | | $93.33 | $151.36 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $173.78 / $263.03
| Professional | | $120.23 | $173.78 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $128.82 / $239.88
| Professional | | $75.86 | $128.82 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $17.78 / $20.89 / $33.88
| Facility | 26 | $17.78 | $20.89 | $33.88 |