- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $119.10 / $119.10 / $119.10
| Facility | 26 | $119.10 | $119.10 | $119.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.86 / $419.84 / $477.13
| Professional | | $365.86 | $419.84 | $477.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.22 / $499.99 / $704.91
| Professional | | $381.22 | $499.99 | $704.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.14 / $594.89 / $937.64
| Professional | | $408.14 | $594.89 | $937.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.27 / $498.16 / $842.08
| Professional | | $403.27 | $498.16 | $842.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.85 / $408.49 / $477.13
| Professional | | $321.85 | $408.49 | $477.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.07 / $615.51 / $861.91
| Professional | | $398.07 | $615.51 | $861.91 |