- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.38 / $96.38 / $96.38
| Professional | | $96.38 | $96.38 | $96.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $41.73 / $41.73 / $41.73
| Professional | 26 | $41.73 | $41.73 | $41.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.04 / $224.79 / $334.80
| Professional | | $166.04 | $224.79 | $334.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.11 / $90.86 / $135.33
| Professional | 26 | $67.11 | $90.86 | $135.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.17 / $232.52 / $1,000.49
| Professional | | $82.17 | $232.52 | $1,000.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.36 / $102.58 / $415.79
| Professional | 26 | $34.36 | $102.58 | $415.79 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $199.60 / $199.60 / $199.60
| Facility | 26 | $199.60 | $199.60 | $199.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.09 / $232.52 / $282.89
| Professional | | $220.09 | $232.52 | $282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.24 / $215.25 / $249.09
| Professional | | $166.24 | $215.25 | $249.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $68.90 / $91.67 / $111.84
| Professional | 26 | $68.90 | $91.67 | $111.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.50 / $82.17 / $247.79
| Professional | | $74.50 | $82.17 | $247.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $30.36 / $34.36 / $112.12
| Professional | 26 | $30.36 | $34.36 | $112.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.50 / $276.00 / $296.70
| Professional | | $214.50 | $276.00 | $296.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.40 / $112.40 / $120.90
| Professional | 26 | $87.40 | $112.40 | $120.90 |