- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $110.50 / $110.50 / $110.50
| Facility | 26 | $110.50 | $110.50 | $110.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $91.85 / $91.85 / $91.85
| Facility | 26 | $91.85 | $91.85 | $91.85 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $217.26 / $368.06 / $905.11
| Facility | 26 | $217.26 | $368.06 | $905.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $193.47 / $331.73 / $712.69
| Facility | 26 | $193.47 | $331.73 | $712.69 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $531.37 / $531.37 / $531.37
| Facility | 26 | $531.37 | $531.37 | $531.37 |