- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $103.00 / $103.00 / $103.00
| Facility | 26 | $103.00 | $103.00 | $103.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.27 / $231.96 / $252.94
| Professional | | $212.27 | $231.96 | $252.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.02 / $115.18 / $221.94
| Professional | | $109.02 | $115.18 | $221.94 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $118.15 / $118.15 / $118.15
| Facility | 26 | $118.15 | $118.15 | $118.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.08 / $218.98 / $736.06
| Professional | | $90.08 | $218.98 | $736.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.09 / $215.94 / $322.48
| Professional | | $145.09 | $215.94 | $322.48 |