- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $21.29 / $21.29 / $35.88
| Facility | 26 | $21.29 | $21.29 | $35.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.66 / $164.16 / $175.22
| Professional | | $160.66 | $164.16 | $175.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.50 / $135.50 / $192.41
| Professional | | $135.50 | $135.50 | $192.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.41 / $167.88 / $209.85
| Professional | | $24.41 | $167.88 | $209.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.31 / $198.39 / $386.94
| Professional | | $152.31 | $198.39 | $386.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.07 / $200.69 / $342.96
| Professional | | $152.07 | $200.69 | $342.96 |