- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $95.50 / $134.90 / $186.21
| Facility | 26 | $95.50 | $134.90 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $131.83 / $186.21
| Professional | | $104.71 | $131.83 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $239.88
| Professional | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $186.21 / $295.12
| Professional | | $117.49 | $186.21 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Facility | 26 | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $181.97 / $1,122.02
| Professional | | $138.04 | $181.97 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $154.88 / $239.88
| Professional | | $138.04 | $154.88 | $239.88 |