- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $35.47 / $67.14 / $124.42
| Facility | 26 | $35.47 | $67.14 | $124.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.38 / $69.40 / $71.42
| Facility | 26 | $67.38 | $69.40 | $71.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $19.39 / $31.81 / $49.49
| Professional | 26 | $19.39 | $31.81 | $49.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $69.40 / $69.40 / $69.40
| Facility | 26 | $69.40 | $69.40 | $69.40 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $69.40 / $71.42 / $114.84
| Facility | 26 | $69.40 | $71.42 | $114.84 |