- 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
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $265.00
| Professional | 26 | $100.00 | $100.00 | $265.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.65 / $33.65 / $35.01
| Professional | 26 | $33.65 | $33.65 | $35.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.46 / $24.92 / $31.09
| Professional | 26 | $22.46 | $24.92 | $31.09 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.90 / $32.90 / $32.90
| Facility | 26 | $32.90 | $32.90 | $32.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $29.71 / $52.79 / $134.09
| Professional | 26 | $29.71 | $52.79 | $134.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.81 / $31.81 / $45.49
| Professional | 26 | $28.81 | $31.81 | $45.49 |