- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $71.25 / $94.31 / $156.38
| Facility | 26 | $71.25 | $94.31 | $156.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.25 / $454.53 / $629.38
| Professional | | $369.25 | $454.53 | $629.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.07 / $472.41 / $1,039.61
| Professional | | $347.07 | $472.41 | $1,039.61 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $85.84 / $85.84 / $85.84
| Facility | 26 | $85.84 | $85.84 | $85.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.59 / $580.71 / $1,135.17
| Professional | | $340.59 | $580.71 | $1,135.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.66 / $559.70 / $933.50
| Professional | | $324.66 | $559.70 | $933.50 |