- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | 26 | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.29 / $146.09 / $224.39
| Professional | | $126.29 | $146.09 | $224.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.41 / $182.71 / $254.97
| Professional | | $148.41 | $182.71 | $254.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.91 / $220.29 / $313.68
| Professional | | $165.91 | $220.29 | $313.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.53 / $192.68 / $361.50
| Professional | | $166.53 | $192.68 | $361.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.29 / $157.24 / $254.49
| Professional | | $126.29 | $157.24 | $254.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.69 / $194.74 / $327.33
| Professional | | $133.69 | $194.74 | $327.33 |