- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $45.03 / $45.03 / $45.03
| Facility | 26 | $45.03 | $45.03 | $45.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.74 / $363.89 / $635.98
| Professional | | $300.74 | $363.89 | $635.98 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.42 / $64.42 / $64.42
| Facility | 26 | $64.42 | $64.42 | $64.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.76 / $528.58 / $2,079.83
| Professional | | $285.76 | $528.58 | $2,079.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.65 / $371.81 / $715.84
| Professional | | $226.65 | $371.81 | $715.84 |