- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $54.95 / $54.95
| Facility | 26 | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $467.74 / $870.96
| Professional | | $354.81 | $467.74 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,698.24 / $1,698.24
| Professional | | $912.01 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $660.69 / $1,659.59
| Professional | | $457.09 | $660.69 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $794.33 / $1,122.02
| Professional | | $389.05 | $794.33 | $1,122.02 |