- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $19.80 / $19.80 / $19.80
| Facility | 26 | $19.80 | $19.80 | $19.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.22 / $174.55 / $174.55
| Professional | | $160.22 | $174.55 | $174.55 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $22.86 / $22.86 / $22.86
| Facility | 26 | $22.86 | $22.86 | $22.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.74 / $209.30 / $818.53
| Professional | | $129.74 | $209.30 | $818.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.59 / $154.91 / $283.85
| Professional | | $104.59 | $154.91 | $283.85 |