- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $100.70 / $100.70 / $100.70
| Facility | 26 | $100.70 | $100.70 | $100.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.31 / $155.55 / $223.10
| Professional | | $113.31 | $155.55 | $223.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $49.99 / $67.59 / $100.70
| Professional | 26 | $49.99 | $67.59 | $100.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.25 / $168.84 / $199.23
| Professional | | $123.25 | $168.84 | $199.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.29 / $77.11 / $90.99
| Professional | 26 | $56.29 | $77.11 | $90.99 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $85.95 / $85.95 / $85.95
| Facility | 26 | $85.95 | $85.95 | $85.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.80 / $188.76 / $458.97
| Professional | | $125.80 | $188.76 | $458.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $61.31 / $97.76 / $226.87
| Professional | 26 | $61.31 | $97.76 | $226.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.30 / $161.10 / $230.93
| Professional | | $125.30 | $161.10 | $230.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.09 / $74.18 / $102.59
| Professional | 26 | $60.09 | $74.18 | $102.59 |