- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $65.06 / $65.06 / $65.06
| Facility | 26 | $65.06 | $65.06 | $65.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.79 / $147.79 / $246.00
| Professional | | $121.79 | $147.79 | $246.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.88 / $167.56 / $205.20
| Professional | | $138.88 | $167.56 | $205.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.57 / $66.69 / $98.49
| Professional | | $32.57 | $66.69 | $98.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.57 / $233.75 / $267.64
| Professional | | $165.57 | $233.75 | $267.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.74 / $136.25 / $204.25
| Professional | | $122.74 | $136.25 | $204.25 |