- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.65 / $38.65 / $38.65
| Facility | 26 | $38.65 | $38.65 | $38.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.57 / $282.68 / $357.48
| Professional | | $263.57 | $282.68 | $357.48 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $44.21 / $44.21 / $44.21
| Facility | 26 | $44.21 | $44.21 | $44.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.91 / $337.06 / $1,306.51
| Professional | | $264.91 | $337.06 | $1,306.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.75 / $268.56 / $498.08
| Professional | | $183.75 | $268.56 | $498.08 |