- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Facility | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $229.09 / $371.54
| Professional | | $169.82 | $229.09 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $389.05 / $407.38
| Professional | | $239.88 | $389.05 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $275.42 / $562.34
| Professional | | $186.21 | $275.42 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $75.86 / $117.49 / $223.87
| Facility | 26 | $75.86 | $117.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $239.88 / $354.81
| Professional | | $165.96 | $239.88 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $263.03 / $537.03
| Professional | | $177.83 | $263.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $239.88 / $302.00
| Professional | | $186.21 | $239.88 | $302.00 |