- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $154.88 / $234.42
| Facility | 26 | $81.28 | $154.88 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $144.54 / $190.55
| Professional | | $114.82 | $144.54 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $177.83
| Professional | | $93.33 | $93.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $181.97 / $263.03
| Professional | | $128.82 | $181.97 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Facility | 26 | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $190.55 / $912.01
| Professional | | $147.91 | $190.55 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $181.97 / $245.47
| Professional | | $147.91 | $181.97 | $245.47 |