- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $65.31 / $69.65 / $132.80
| Facility | 26 | $65.31 | $69.65 | $132.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.87 / $148.79 / $178.83
| Professional | | $119.87 | $148.79 | $178.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.81 / $194.81 / $194.81
| Professional | | $194.81 | $194.81 | $194.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.88 / $168.20 / $245.27
| Professional | | $113.88 | $168.20 | $245.27 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $139.91 / $284.58 / $284.58
| Facility | 26 | $139.91 | $284.58 | $284.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.56 / $167.81 / $936.67
| Professional | | $117.56 | $167.81 | $936.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.56 / $146.28 / $245.42
| Professional | | $117.56 | $146.28 | $245.42 |