- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $497.95 / $497.95 / $497.95
| Facility | 26 | $497.95 | $497.95 | $497.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.11 / $220.21 / $1,220.00
| Professional | | $196.11 | $220.21 | $1,220.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.63 / $320.74 / $433.94
| Professional | | $272.63 | $320.74 | $433.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.92 / $376.97 / $558.40
| Professional | | $221.92 | $376.97 | $558.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.26 / $324.33 / $505.20
| Professional | | $160.26 | $324.33 | $505.20 |