- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $77.90 / $77.90 / $77.90
| Facility | 26 | $77.90 | $77.90 | $77.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.85 / $181.20 / $265.63
| Professional | | $143.85 | $181.20 | $265.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $62.75 / $75.41 / $114.84
| Professional | 26 | $62.75 | $75.41 | $114.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.48 / $64.48 / $64.48
| Facility | 26 | $64.48 | $64.48 | $64.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.19 / $458.75 / $618.22
| Professional | | $287.19 | $458.75 | $618.22 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $132.19 / $198.34 / $265.12
| Professional | 26 | $132.19 | $198.34 | $265.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $171.43 / $267.55 / $643.64
| Facility | 26 | $171.43 | $267.55 | $643.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.33 / $340.31 / $557.66
| Professional | | $211.33 | $340.31 | $557.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $92.65 / $145.66 / $240.80
| Professional | 26 | $92.65 | $145.66 | $240.80 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $148.56 / $244.16 / $506.80
| Facility | 26 | $148.56 | $244.16 | $506.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.95 / $267.95 / $504.24
| Professional | | $267.95 | $267.95 | $504.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $114.70 / $114.70 / $215.83
| Professional | 26 | $114.70 | $114.70 | $215.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $343.65 / $343.65 / $343.65
| Facility | 26 | $343.65 | $343.65 | $343.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.00 / $325.38 / $1,115.94
| Professional | | $179.00 | $325.38 | $1,115.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.12 / $145.41 / $476.34
| Professional | 26 | $80.12 | $145.41 | $476.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.00 / $319.33 / $587.32
| Professional | | $179.00 | $319.33 | $587.32 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $80.12 / $141.47 / $256.88
| Professional | 26 | $80.12 | $141.47 | $256.88 |