- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $115.99 / $129.90 / $129.90
| Facility | 26 | $115.99 | $129.90 | $129.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.31 / $339.94 / $371.76
| Professional | | $257.31 | $339.94 | $371.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.15 / $458.46 / $672.61
| Professional | | $350.15 | $458.46 | $672.61 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $237.98 / $237.98 / $237.98
| Facility | 26 | $237.98 | $237.98 | $237.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.29 / $647.78 / $1,127.99
| Professional | | $411.29 | $647.78 | $1,127.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.51 / $561.51 / $594.67
| Professional | | $561.51 | $561.51 | $594.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.58 / $490.00 / $667.74
| Professional | | $394.58 | $490.00 | $667.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $150.79 / $187.90 / $275.39
| Professional | 26 | $150.79 | $187.90 | $275.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.10 / $872.50 / $1,363.28
| Professional | | $408.10 | $872.50 | $1,363.28 |