- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Facility | 26 | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Professional | 26 | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $106.64 / $123.63 / $181.83
| Professional | 26 | $106.64 | $123.63 | $181.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,694.22 / $2,694.22 / $2,694.22
| Facility | 26 | $2,694.22 | $2,694.22 | $2,694.22 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $122.94 / $184.53 / $196.15
| Professional | 26 | $122.94 | $184.53 | $196.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.45 / $99.06 / $147.60
| Professional | 26 | $75.45 | $99.06 | $147.60 |