- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.71 / $243.23 / $1,338.04
| Professional | | $189.71 | $243.23 | $1,338.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.47 / $67.33 / $359.20
| Professional | 26 | $56.47 | $67.33 | $359.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.12 / $94.12 / $321.79
| Professional | | $94.12 | $94.12 | $321.79 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $94.12 / $94.12 / $116.35
| Facility | 26 | $94.12 | $94.12 | $116.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.79 / $441.16 / $610.30
| Professional | | $321.79 | $441.16 | $610.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.97 / $94.03 / $148.37
| Professional | 26 | $60.97 | $94.03 | $148.37 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $94.12 / $94.12 / $116.35
| Facility | 26 | $94.12 | $94.12 | $116.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.31 / $353.04 / $519.55
| Professional | | $217.31 | $353.04 | $519.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.97 / $94.12 / $123.83
| Professional | 26 | $60.97 | $94.12 | $123.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.09 / $319.06 / $573.50
| Professional | | $199.09 | $319.06 | $573.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $55.09 / $55.79 / $114.08
| Professional | 26 | $55.09 | $55.79 | $114.08 |