- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.56 / $52.56 / $52.56
| Facility | 26 | $52.56 | $52.56 | $52.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.16 / $136.11 / $230.92
| Professional | | $111.16 | $136.11 | $230.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.34 / $61.34 / $61.34
| Professional | | $61.34 | $61.34 | $61.34 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $61.14 / $61.14 / $61.14
| Facility | 26 | $61.14 | $61.14 | $61.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.72 / $271.70 / $2,245.69
| Professional | | $95.72 | $271.70 | $2,245.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.78 / $266.33 / $716.62
| Professional | | $109.78 | $266.33 | $716.62 |