- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $295.75 / $295.75 / $295.75
| Facility | 26 | $295.75 | $295.75 | $295.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.63 / $307.06 / $410.19
| Professional | | $259.63 | $307.06 | $410.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.45 / $402.20 / $555.48
| Professional | | $308.45 | $402.20 | $555.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.98 / $192.46 / $261.23
| Professional | | $25.98 | $192.46 | $261.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $495.90 / $495.90 / $495.90
| Facility | 26 | $495.90 | $495.90 | $495.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.96 / $585.55 / $673.71
| Professional | | $447.96 | $585.55 | $673.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.92 / $336.26 / $428.98
| Professional | | $241.92 | $336.26 | $428.98 |