- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $65.89 / $65.89 / $65.89
| Facility | 26 | $65.89 | $65.89 | $65.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.54 / $340.54 / $480.16
| Professional | | $340.54 | $340.54 | $480.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.71 / $392.57 / $644.07
| Professional | | $328.71 | $392.57 | $644.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.99 / $230.56 / $313.86
| Professional | | $32.99 | $230.56 | $313.86 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $890.71 / $890.71 / $890.71
| Facility | 26 | $890.71 | $890.71 | $890.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.35 / $691.64 / $735.19
| Professional | | $481.35 | $691.64 | $735.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.77 / $366.31 / $609.00
| Professional | | $299.77 | $366.31 | $609.00 |