- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.28 / $153.64 / $267.95
| Facility | 26 | $120.28 | $153.64 | $267.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.56 / $335.85 / $474.08
| Professional | | $272.56 | $335.85 | $474.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $132.99 / $132.99 / $132.99
| Facility | 26 | $132.99 | $132.99 | $132.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.82 / $524.29 / $772.02
| Professional | | $316.82 | $524.29 | $772.02 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $135.43 / $135.43 / $135.43
| Facility | 26 | $135.43 | $135.43 | $135.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.85 / $681.88 / $1,195.77
| Professional | | $421.85 | $681.88 | $1,195.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.12 / $589.61 / $1,090.61
| Professional | | $444.12 | $589.61 | $1,090.61 |