- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.89 / $104.89 / $104.89
| Facility | 26 | $104.89 | $104.89 | $104.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.94 / $327.37 / $483.52
| Professional | | $274.94 | $327.37 | $483.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.89 / $491.63 / $502.71
| Professional | | $417.89 | $491.63 | $502.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.86 / $770.46 / $869.53
| Professional | | $456.86 | $770.46 | $869.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.99 / $415.72 / $640.72
| Professional | | $246.99 | $415.72 | $640.72 |