- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $249.84 / $249.84 / $249.84
| Facility | 26 | $249.84 | $249.84 | $249.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.69 / $289.41 / $319.35
| Professional | | $275.69 | $289.41 | $319.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.98 / $336.98 / $584.44
| Professional | | $336.98 | $336.98 | $584.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.02 / $650.80 / $652.48
| Professional | | $351.02 | $650.80 | $652.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.48 / $272.33 / $496.87
| Professional | | $221.48 | $272.33 | $496.87 |