- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $79.55 / $79.55 / $79.55
| Facility | 26 | $79.55 | $79.55 | $79.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.99 / $239.96 / $1,267.16
| Professional | | $197.99 | $239.96 | $1,267.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.87 / $262.06 / $448.73
| Professional | | $233.87 | $262.06 | $448.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.54 / $144.46 / $221.57
| Professional | | $52.54 | $144.46 | $221.57 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $616.40 / $616.40 / $616.40
| Facility | 26 | $616.40 | $616.40 | $616.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.64 / $376.97 / $407.04
| Professional | | $354.64 | $376.97 | $407.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.70 / $278.33 / $367.41
| Professional | | $221.70 | $278.33 | $367.41 |