- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $251.19 / $371.54
| Professional | | $177.83 | $251.19 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.48 / $75.86 / $204.17
| Professional | 26 | $52.48 | $75.86 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $151.36 / $204.17 / $295.12
| Professional | TC | $151.36 | $204.17 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Facility | 26 | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $891.25
| Professional | | $302.00 | $302.00 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $426.58 / $812.83
| Professional | | $275.42 | $426.58 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $70.79 / $81.28 / $173.78
| Professional | 26 | $70.79 | $81.28 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $204.17 / $354.81 / $645.65
| Professional | TC | $204.17 | $354.81 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $891.25
| Professional | | $234.42 | $234.42 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $58.88 / $229.09
| Professional | 26 | $58.88 | $58.88 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Professional | TC | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $407.38 / $707.95
| Professional | | $218.78 | $407.38 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $75.86 / $186.21
| Professional | 26 | $56.23 | $75.86 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $162.18 / $245.47 / $524.81
| Professional | TC | $162.18 | $245.47 | $524.81 |