- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $43.82 / $43.82 / $43.82
| Facility | 26 | $43.82 | $43.82 | $43.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.50 / $240.40 / $240.40
| Professional | | $182.50 | $240.40 | $240.40 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.66 / $62.66 / $62.66
| Facility | 26 | $62.66 | $62.66 | $62.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.30 / $301.82 / $1,172.47
| Professional | | $235.30 | $301.82 | $1,172.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.16 / $266.50 / $529.12
| Professional | | $163.16 | $266.50 | $529.12 |