- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $243.26 / $257.66 / $294.46
| Facility | 26 | $243.26 | $257.66 | $294.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.88 / $290.31 / $454.97
| Professional | | $257.88 | $290.31 | $454.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.74 / $401.04 / $639.76
| Professional | | $257.74 | $401.04 | $639.76 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $265.56 / $265.56 / $265.56
| Facility | 26 | $265.56 | $265.56 | $265.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.89 / $420.54 / $721.68
| Professional | | $291.89 | $420.54 | $721.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.47 / $363.43 / $604.41
| Professional | | $259.47 | $363.43 | $604.41 |