- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $19.95 / $41.69 / $104.71
| Facility | 26 | $19.95 | $41.69 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $190.55 / $389.05
| Professional | | $144.54 | $190.55 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $204.17 / $426.58
| Professional | | $144.54 | $204.17 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $5.62 / $31.62 / $97.72
| Facility | 26 | $5.62 | $31.62 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $275.42 / $537.03
| Professional | | $154.88 | $275.42 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $208.93 / $426.58
| Professional | | $144.54 | $208.93 | $426.58 |