- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $78.12 / $78.12 / $120.16
| Facility | 26 | $78.12 | $78.12 | $120.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.05 / $367.50 / $487.65
| Professional | | $328.05 | $367.50 | $487.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.88 / $410.01 / $582.21
| Professional | | $341.88 | $410.01 | $582.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.54 / $276.85 / $407.43
| Professional | | $75.54 | $276.85 | $407.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.95 / $87.95 / $87.95
| Facility | 26 | $87.95 | $87.95 | $87.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.60 / $637.29 / $942.75
| Professional | | $331.60 | $637.29 | $942.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.40 / $489.73 / $837.02
| Professional | | $361.40 | $489.73 | $837.02 |