- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $177.27 / $177.27 / $177.27
| Facility | 26 | $177.27 | $177.27 | $177.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.84 / $104.42 / $123.86
| Professional | | $77.84 | $104.42 | $123.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.91 / $156.09 / $213.82
| Professional | | $149.91 | $156.09 | $213.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.71 / $203.79 / $261.76
| Professional | | $102.71 | $203.79 | $261.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.89 / $143.31 / $299.64
| Professional | | $94.89 | $143.31 | $299.64 |