- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Facility | 26 | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $173.78 / $354.81
| Professional | | $141.25 | $173.78 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $61.66 / $75.86 / $275.42
| Professional | 26 | $61.66 | $75.86 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $186.21 / $302.00
| Professional | | $131.83 | $186.21 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $81.28 / $131.83
| Professional | 26 | $58.88 | $81.28 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Professional | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $158.49 / $245.47
| Professional | | $128.82 | $158.49 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $70.79 / $109.65
| Professional | 26 | $54.95 | $70.79 | $109.65 |