- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.56 / $62.56 / $75.45
| Facility | 26 | $62.56 | $62.56 | $75.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.37 / $107.93 / $144.93
| Professional | | $75.37 | $107.93 | $144.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.05 / $107.02 / $162.41
| Professional | | $92.05 | $107.02 | $162.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.53 / $107.44 / $160.19
| Professional | | $79.53 | $107.44 | $160.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.03 / $102.69 / $179.58
| Professional | | $80.03 | $102.69 | $179.58 |