- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.49 / $318.58 / $896.69
| Professional | | $213.49 | $318.58 | $896.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.46 / $61.07 / $302.00
| Professional | 26 | $52.46 | $61.07 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.39 / $89.39 / $402.76
| Professional | | $89.39 | $89.39 | $402.76 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $89.39 / $89.39 / $110.50
| Facility | 26 | $89.39 | $89.39 | $110.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.25 / $404.23 / $642.78
| Professional | | $362.25 | $404.23 | $642.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.95 / $89.39 / $142.66
| Professional | 26 | $57.95 | $89.39 | $142.66 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $89.39 / $89.39 / $110.50
| Facility | 26 | $89.39 | $89.39 | $110.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.24 / $425.43 / $652.79
| Professional | | $255.24 | $425.43 | $652.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.95 / $89.39 / $119.04
| Professional | 26 | $57.95 | $89.39 | $119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.89 / $320.94 / $500.48
| Professional | | $239.89 | $320.94 | $500.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.96 / $53.59 / $109.66
| Professional | 26 | $52.96 | $53.59 | $109.66 |