- 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
- $112.13 / $243.63 / $317.30
| Professional | 26 | $112.13 | $243.63 | $317.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $137.31 / $164.52 / $246.66
| Professional | 26 | $137.31 | $164.52 | $246.66 |
- 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
- $166.56 / $250.50 / $266.27
| Professional | 26 | $166.56 | $250.50 | $266.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $104.30 / $134.22 / $203.99
| Professional | 26 | $104.30 | $134.22 | $203.99 |