- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $22.38 / $22.38 / $22.38
| Facility | 26 | $22.38 | $22.38 | $22.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.13 / $179.60 / $179.60
| Professional | | $165.13 | $179.60 | $179.60 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.91 / $25.91 / $25.91
| Facility | 26 | $25.91 | $25.91 | $25.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.46 / $215.81 / $840.37
| Professional | | $148.46 | $215.81 | $840.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.05 / $158.77 / $303.00
| Professional | | $115.05 | $158.77 | $303.00 |