- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $82.05 / $82.05 / $82.05
| Facility | 26 | $82.05 | $82.05 | $82.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.63 / $126.21 / $151.16
| Professional | | $124.63 | $126.21 | $151.16 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $95.47 / $95.47 / $95.47
| Facility | 26 | $95.47 | $95.47 | $95.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.46 / $174.54 / $817.13
| Professional | | $146.46 | $174.54 | $817.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.74 / $183.45 / $378.83
| Professional | | $104.74 | $183.45 | $378.83 |