- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $85.74 / $154.35 / $162.93
| Facility | 26 | $85.74 | $154.35 | $162.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.82 / $144.52 / $190.30
| Professional | | $138.82 | $144.52 | $190.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.56 / $175.56 / $175.56
| Professional | | $175.56 | $175.56 | $175.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.90 / $195.56 / $244.86
| Professional | | $127.90 | $195.56 | $244.86 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $172.46 / $172.46 / $172.46
| Facility | 26 | $172.46 | $172.46 | $172.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.66 / $189.03 / $920.53
| Professional | | $152.66 | $189.03 | $920.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.53 / $180.02 / $290.74
| Professional | | $148.53 | $180.02 | $290.74 |