- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $17.23 / $17.23 / $36.28
| Facility | 26 | $17.23 | $17.23 | $36.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.06 / $220.54 / $1,156.81
| Professional | | $138.06 | $220.54 | $1,156.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.21 / $123.16 / $270.77
| Professional | | $21.21 | $123.16 | $270.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.46 / $256.50 / $349.48
| Professional | | $186.46 | $256.50 | $349.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.11 / $35.21 / $261.26
| Professional | | $27.11 | $35.21 | $261.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.37 / $283.98 / $349.48
| Professional | | $159.37 | $283.98 | $349.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.88 / $163.46 / $393.39
| Professional | | $146.88 | $163.46 | $393.39 |