- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.77 / $387.95 / $1,518.64
| Professional | | $238.77 | $387.95 | $1,518.64 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $78.03 / $91.03 / $378.42
| Professional | 26 | $78.03 | $91.03 | $378.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.97 / $131.97 / $480.58
| Professional | | $131.97 | $131.97 | $480.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $131.97 / $131.97 / $163.15
| Facility | 26 | $131.97 | $131.97 | $163.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.33 / $532.53 / $748.90
| Professional | | $415.33 | $532.53 | $748.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.05 / $131.97 / $209.72
| Professional | 26 | $87.05 | $131.97 | $209.72 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $131.97 / $131.97 / $163.15
| Facility | 26 | $131.97 | $131.97 | $163.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.83 / $503.07 / $776.83
| Professional | | $301.83 | $503.07 | $776.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.05 / $131.97 / $174.61
| Professional | 26 | $87.05 | $131.97 | $174.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.45 / $395.54 / $591.36
| Professional | | $283.45 | $395.54 | $591.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $77.91 / $79.61 / $160.99
| Professional | 26 | $77.91 | $79.61 | $160.99 |