- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.44 / $64.44 / $64.44
| Facility | 26 | $64.44 | $64.44 | $64.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.48 / $91.48 / $110.60
| Professional | | $77.48 | $91.48 | $110.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.55 / $109.55 / $159.24
| Professional | | $109.55 | $109.55 | $159.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.21 / $115.35 / $136.11
| Professional | | $84.21 | $115.35 | $136.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.41 / $105.73 / $334.98
| Professional | | $83.41 | $105.73 | $334.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.45 / $91.15 / $144.56
| Professional | | $68.45 | $91.15 | $144.56 |