- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $125.89 / $512.86
| Facility | 26 | $67.61 | $125.89 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $125.89 / $158.49
| Professional | | $104.71 | $125.89 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $128.82 / $208.93
| Professional | | $83.18 | $128.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $141.25 / $269.15
| Professional | | $117.49 | $141.25 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $199.53 / $467.74 / $467.74
| Facility | 26 | $199.53 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $154.88 / $1,122.02
| Professional | | $117.49 | $154.88 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $141.25 / $223.87
| Professional | | $112.20 | $141.25 | $223.87 |