- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $157.90 / $157.90 / $157.90
| Facility | 26 | $157.90 | $157.90 | $157.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.60 / $57.70 / $65.98
| Professional | | $42.60 | $57.70 | $65.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.15 / $74.93 / $121.18
| Professional | | $67.15 | $74.93 | $121.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.60 / $91.29 / $124.08
| Professional | | $53.60 | $91.29 | $124.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.24 / $75.18 / $114.72
| Professional | | $57.24 | $75.18 | $114.72 |