- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $139.32 / $337.04 / $421.28
| Facility | 26 | $139.32 | $337.04 | $421.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.44 / $244.82 / $385.52
| Professional | | $165.44 | $244.82 | $385.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.35 / $223.26 / $259.54
| Professional | | $195.35 | $223.26 | $259.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.27 / $253.37 / $398.21
| Professional | | $197.27 | $253.37 | $398.21 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $235.26 / $454.15 / $454.15
| Facility | 26 | $235.26 | $454.15 | $454.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.43 / $252.63 / $1,682.32
| Professional | | $202.43 | $252.63 | $1,682.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.32 / $240.00 / $342.00
| Professional | | $198.32 | $240.00 | $342.00 |