- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $407.38 / $851.14
| Professional | | $338.84 | $407.38 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.65 / $134.90 / $204.17
| Professional | 26 | $109.65 | $134.90 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $229.09 / $263.03 / $467.74
| Professional | TC | $229.09 | $263.03 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $446.68 / $794.33
| Professional | | $323.59 | $446.68 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $173.78 / $354.81
| Professional | 26 | $107.15 | $173.78 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $213.80 / $309.03 / $549.54
| Professional | TC | $213.80 | $309.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $1,445.44
| Professional | | $354.81 | $501.19 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $112.20 / $158.49 / $436.52
| Professional | 26 | $112.20 | $158.49 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $245.47 / $346.74 / $1,000.00
| Professional | TC | $245.47 | $346.74 | $1,000.00 |