- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $100.10 / $100.10 / $196.95
| Facility | 26 | $100.10 | $100.10 | $196.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.00 / $163.01 / $340.40
| Professional | | $129.00 | $163.01 | $340.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.01 / $202.01 / $202.01
| Professional | | $202.01 | $202.01 | $202.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.81 / $214.01 / $483.96
| Professional | | $142.81 | $214.01 | $483.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $198.06 / $198.06 / $198.06
| Facility | 26 | $198.06 | $198.06 | $198.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.43 / $203.70 / $956.27
| Professional | | $161.43 | $203.70 | $956.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.22 / $197.78 / $367.63
| Professional | | $156.22 | $197.78 | $367.63 |