- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $55.56 / $68.70 / $125.95
| Facility | 26 | $55.56 | $68.70 | $125.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.74 / $419.29 / $763.60
| Professional | | $300.74 | $419.29 | $763.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.05 / $473.60 / $782.57
| Professional | | $358.05 | $473.60 | $782.57 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.42 / $64.42 / $64.42
| Facility | 26 | $64.42 | $64.42 | $64.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.93 / $522.19 / $949.30
| Professional | | $348.93 | $522.19 | $949.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.87 / $504.00 / $894.20
| Professional | | $327.87 | $504.00 | $894.20 |