- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $95.32 / $100.00 / $100.00
| Facility | 26 | $95.32 | $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
- $75.73 / $89.11 / $128.34
| Professional | 26 | $75.73 | $89.11 | $128.34 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.54 / $104.54 / $104.54
| Facility | 26 | $104.54 | $104.54 | $104.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $93.18 / $147.75 / $690.00
| Professional | 26 | $93.18 | $147.75 | $690.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.53 / $102.79 / $129.53
| Professional | 26 | $87.53 | $102.79 | $129.53 |