- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $133.08 / $133.08 / $133.08
| Facility | 26 | $133.08 | $133.08 | $133.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.09 / $372.49 / $452.94
| Professional | | $354.09 | $372.49 | $452.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.99 / $568.86 / $812.95
| Professional | | $326.99 | $568.86 | $812.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.64 / $234.96 / $355.81
| Professional | | $80.64 | $234.96 | $355.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $887.76 / $887.76 / $887.76
| Facility | 26 | $887.76 | $887.76 | $887.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.74 / $654.48 / $859.29
| Professional | | $451.74 | $654.48 | $859.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.44 / $456.49 / $654.63
| Professional | | $302.44 | $456.49 | $654.63 |