- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $133.52 / $133.52 / $133.52
| Facility | 26 | $133.52 | $133.52 | $133.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.44 / $238.11 / $334.74
| Professional | | $165.44 | $238.11 | $334.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.46 / $249.95 / $294.94
| Professional | | $182.46 | $249.95 | $294.94 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $112.79 / $112.79 / $112.79
| Facility | 26 | $112.79 | $112.79 | $112.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.26 / $248.38 / $649.57
| Professional | | $189.26 | $248.38 | $649.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.21 / $232.02 / $295.58
| Professional | | $164.21 | $232.02 | $295.58 |