- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $86.37 / $86.37 / $86.37
| Facility | 26 | $86.37 | $86.37 | $86.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.89 / $322.83 / $554.66
| Professional | | $252.89 | $322.83 | $554.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $70.23 / $86.37 / $191.84
| Professional | 26 | $70.23 | $86.37 | $191.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $70.83 / $70.83 / $70.83
| Facility | 26 | $70.83 | $70.83 | $70.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.02 / $884.04 / $1,072.21
| Professional | | $527.02 | $884.04 | $1,072.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $147.33 / $242.77 / $294.45
| Professional | 26 | $147.33 | $242.77 | $294.45 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $188.26 / $293.83 / $706.85
| Facility | 26 | $188.26 | $293.83 | $706.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.21 / $588.45 / $993.12
| Professional | | $429.21 | $588.45 | $993.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $96.92 / $159.84 / $271.45
| Professional | 26 | $96.92 | $159.84 | $271.45 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $163.15 / $259.06 / $556.58
| Facility | 26 | $163.15 | $259.06 | $556.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.35 / $568.89 / $899.40
| Professional | | $463.35 | $568.89 | $899.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $125.86 / $154.53 / $254.08
| Professional | 26 | $125.86 | $154.53 | $254.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $792.40 / $792.40 / $792.40
| Facility | 26 | $792.40 | $792.40 | $792.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.10 / $621.04 / $2,854.54
| Professional | | $365.10 | $621.04 | $2,854.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.67 / $165.78 / $536.20
| Professional | 26 | $91.67 | $165.78 | $536.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.47 / $600.95 / $1,110.22
| Professional | | $333.47 | $600.95 | $1,110.22 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.67 / $160.02 / $279.74
| Professional | 26 | $91.67 | $160.02 | $279.74 |