- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $137.61 / $137.61 / $137.61
| Facility | 26 | $137.61 | $137.61 | $137.61 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $297.20 / $306.12 / $315.02
| Facility | 26 | $297.20 | $306.12 | $315.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $104.92 / $156.93 / $7,334.16
| Professional | 26 | $104.92 | $156.93 | $7,334.16 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $306.12 / $306.12 / $306.12
| Facility | 26 | $306.12 | $306.12 | $306.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $306.12 / $315.02 / $571.32
| Facility | 26 | $306.12 | $315.02 | $571.32 |