- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $219.69 / $219.69 / $219.69
| Facility | 26 | $219.69 | $219.69 | $219.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.68 / $267.73 / $280.88
| Professional | | $257.68 | $267.73 | $280.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.29 / $289.01 / $1,282.51
| Professional | | $272.29 | $289.01 | $1,282.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.89 / $520.55 / $1,143.55
| Professional | | $291.89 | $520.55 | $1,143.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.62 / $298.97 / $622.98
| Professional | | $258.62 | $298.97 | $622.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $215.24 / $245.38 / $510.90
| Professional | 26 | $215.24 | $245.38 | $510.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.26 / $402.00 / $768.68
| Professional | | $233.26 | $402.00 | $768.68 |