- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $79.95 / $79.95 / $79.95
| Facility | 26 | $79.95 | $79.95 | $79.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.52 / $260.52 / $625.26
| Professional | | $260.52 | $260.52 | $625.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.08 / $299.80 / $1,643.00
| Professional | | $124.08 | $299.80 | $1,643.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.55 / $311.33 / $843.99
| Professional | | $215.55 | $311.33 | $843.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.07 / $536.79 / $536.79
| Professional | | $221.07 | $536.79 | $536.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.67 / $166.62 / $166.62
| Professional | 26 | $75.67 | $166.62 | $166.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.66 / $415.03 / $621.96
| Professional | | $205.66 | $415.03 | $621.96 |