- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $128.11 / $128.11 / $128.11
| Facility | 26 | $128.11 | $128.11 | $128.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.21 / $186.36 / $186.36
| Professional | | $170.21 | $186.36 | $186.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.04 / $211.04 / $349.24
| Professional | | $211.04 | $211.04 | $349.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.84 / $389.01 / $402.22
| Professional | | $219.84 | $389.01 | $402.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.48 / $155.33 / $329.86
| Professional | | $99.48 | $155.33 | $329.86 |