- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $200.00 / $200.00 / $4,408.17
| Facility | 26 | $200.00 | $200.00 | $4,408.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.53 / $200.00 / $330.24
| Professional | 26 | $22.53 | $200.00 | $330.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $134.21 / $160.87 / $321.11
| Professional | 26 | $134.21 | $160.87 | $321.11 |
- 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
- $165.08 / $249.01 / $264.70
| Professional | 26 | $165.08 | $249.01 | $264.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $103.38 / $133.02 / $202.20
| Professional | 26 | $103.38 | $133.02 | $202.20 |