- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $200.00 / $200.00 / $2,896.30
| Facility | 26 | $200.00 | $200.00 | $2,896.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $82.28 / $200.00 / $293.72
| Professional | 26 | $82.28 | $200.00 | $293.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $101.67 / $129.69 / $189.30
| Professional | 26 | $101.67 | $129.69 | $189.30 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $4,095.91 / $4,095.91 / $4,095.91
| Facility | 26 | $4,095.91 | $4,095.91 | $4,095.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $127.90 / $171.76 / $193.74
| Professional | 26 | $127.90 | $171.76 | $193.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.67 / $94.55 / $157.19
| Professional | 26 | $75.67 | $94.55 | $157.19 |