- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $109.35 / $109.35 / $109.35
| Facility | 26 | $109.35 | $109.35 | $109.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.55 / $219.49 / $531.65
| Professional | | $168.55 | $219.49 | $531.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.24 / $299.33 / $466.38
| Professional | | $205.24 | $299.33 | $466.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.09 / $146.85 / $253.92
| Professional | | $80.09 | $146.85 | $253.92 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $324.95 / $324.95 / $324.95
| Facility | 26 | $324.95 | $324.95 | $324.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.69 / $420.81 / $450.36
| Professional | | $357.69 | $420.81 | $450.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.90 / $252.63 / $407.50
| Professional | | $205.90 | $252.63 | $407.50 |