- 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 / $244.53
| Professional | 26 | $200.00 | $200.00 | $244.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $121.41 / $145.25 / $219.37
| Professional | 26 | $121.41 | $145.25 | $219.37 |
- 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
- $148.22 / $227.00 / $241.30
| Professional | 26 | $148.22 | $227.00 | $241.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $92.34 / $119.44 / $180.60
| Professional | 26 | $92.34 | $119.44 | $180.60 |