- 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
- $110.55 / $132.69 / $198.16
| Professional | 26 | $110.55 | $132.69 | $198.16 |
- 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
- $133.85 / $204.20 / $217.04
| Professional | 26 | $133.85 | $204.20 | $217.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.98 / $107.86 / $158.41
| Professional | 26 | $80.98 | $107.86 | $158.41 |