- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.02 / $64.02 / $64.02
| Facility | 26 | $64.02 | $64.02 | $64.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.46 / $95.34 / $118.30
| Professional | | $84.46 | $95.34 | $118.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.06 / $88.30 / $133.86
| Professional | | $75.06 | $88.30 | $133.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.02 / $104.03 / $195.41
| Professional | | $81.02 | $104.03 | $195.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.49 / $116.80 / $162.51
| Professional | | $96.49 | $116.80 | $162.51 |