- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $144.54 / $295.12 / $380.19
| Facility | 26 | $144.54 | $295.12 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $208.93 / $363.08
| Professional | | $177.83 | $208.93 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $229.09 / $398.11
| Professional | | $38.90 | $229.09 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $229.09 / $407.38
| Professional | | $158.49 | $229.09 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Facility | 26 | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $1,513.56
| Professional | | $1,348.96 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $218.78 / $363.08
| Professional | | $154.88 | $218.78 | $363.08 |