- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $34.67 / $34.67
| Facility | 26 | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $181.97 / $288.40
| Professional | | $147.91 | $181.97 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $8.71 / $40.74 / $58.88
| Facility | 26 | $8.71 | $40.74 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $501.19 / $794.33
| Professional | | $151.36 | $501.19 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $151.36 / $309.03
| Professional | | $109.65 | $151.36 | $309.03 |