- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.26 / $123.66 / $177.95
| Professional | | $111.26 | $123.66 | $177.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.78 / $29.43 / $32.11
| Professional | 26 | $23.78 | $29.43 | $32.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.85 / $47.85 / $174.57
| Professional | | $47.85 | $47.85 | $174.57 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $47.85 / $47.85 / $59.15
| Facility | 26 | $47.85 | $47.85 | $59.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.72 / $174.57 / $292.24
| Professional | | $121.72 | $174.57 | $292.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $26.31 / $43.37 / $69.58
| Professional | 26 | $26.31 | $43.37 | $69.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $47.85 / $47.85 / $59.15
| Facility | 26 | $47.85 | $47.85 | $59.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.55 / $203.86 / $360.06
| Professional | | $132.55 | $203.86 | $360.06 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $26.13 / $47.85 / $57.91
| Professional | 26 | $26.13 | $47.85 | $57.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.64 / $138.58 / $243.37
| Professional | | $120.64 | $138.58 | $243.37 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $29.00 / $29.59 / $51.97
| Professional | 26 | $29.00 | $29.59 | $51.97 |