- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $158.49 / $158.49 / $245.47
| Facility | 26 | $158.49 | $158.49 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $204.17 / $426.58
| Professional | | $169.82 | $204.17 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $263.03 / $389.05
| Professional | | $169.82 | $263.03 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $281.84 / $407.38
| Professional | | $190.55 | $281.84 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $316.23 / $588.84
| Professional | | $223.87 | $316.23 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $158.49 / $223.87 / $457.09
| Professional | 26 | $158.49 | $223.87 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $223.87 / $239.88
| Professional | | $181.97 | $223.87 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $263.03 / $436.52
| Professional | | $186.21 | $263.03 | $436.52 |