- 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
- $181.97 / $213.80 / $302.00
| Professional | | $181.97 | $213.80 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $707.95
| Professional | | $257.04 | $257.04 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $263.03 / $478.63
| Professional | | $151.36 | $263.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $323.59 / $707.95
| Professional | | $245.47 | $323.59 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $302.00 / $691.83
| Professional | | $186.21 | $302.00 | $691.83 |