- 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
- $64.27 / $200.00 / $275.54
| Professional | 26 | $64.27 | $200.00 | $275.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $82.24 / $97.66 / $148.97
| Professional | 26 | $82.24 | $97.66 | $148.97 |
- 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
- $100.63 / $148.75 / $158.11
| Professional | 26 | $100.63 | $148.75 | $158.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $62.27 / $73.26 / $121.80
| Professional | 26 | $62.27 | $73.26 | $121.80 |