- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $118.89 / $153.61 / $282.51
| Facility | 26 | $118.89 | $153.61 | $282.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.72 / $428.05 / $620.50
| Professional | | $291.72 | $428.05 | $620.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $122.05 / $122.05 / $122.05
| Facility | 26 | $122.05 | $122.05 | $122.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.58 / $411.52 / $823.04
| Professional | | $288.58 | $411.52 | $823.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $125.89 / $125.89 / $125.89
| Facility | 26 | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.98 / $518.95 / $834.13
| Professional | | $284.98 | $518.95 | $834.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.23 / $441.49 / $774.31
| Professional | | $287.23 | $441.49 | $774.31 |