- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $91.20 / $91.20
| Facility | 26 | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $169.82 / $389.05
| Professional | | $131.83 | $169.82 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $74.13 / $91.20 / $229.09
| Professional | 26 | $74.13 | $91.20 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $75.86 / $75.86
| Facility | 26 | $66.07 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $371.54 / $562.34
| Professional | | $257.04 | $371.54 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $151.36 / $223.87 / $331.13
| Professional | 26 | $151.36 | $223.87 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $75.86 / $288.40 / $794.33
| Facility | 26 | $75.86 | $288.40 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $295.12 / $562.34
| Professional | | $204.17 | $295.12 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $165.96 / $275.42
| Professional | 26 | $97.72 | $165.96 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $257.04 / $316.23 / $616.60
| Facility | 26 | $257.04 | $316.23 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $363.08
| Professional | | $234.42 | $234.42 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $134.90 / $134.90 / $208.93
| Professional | 26 | $134.90 | $134.90 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Facility | 26 | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $331.13 / $3,388.44
| Professional | | $173.78 | $331.13 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.50 / $158.49 / $630.96
| Professional | 26 | $95.50 | $158.49 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $309.03 / $575.44
| Professional | | $173.78 | $309.03 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.50 / $147.91 / $288.40
| Professional | 26 | $95.50 | $147.91 | $288.40 |