- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $302.00 / $457.09
| Professional | | $218.78 | $302.00 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $144.54 / $194.98 / $549.54
| Professional | 26 | $144.54 | $194.98 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $109.65 / $144.54 / $199.53
| Professional | TC | $109.65 | $144.54 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $1,202.26
| Professional | | $331.13 | $331.13 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $177.83 / $177.83 / $645.65
| Professional | 26 | $177.83 | $177.83 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $158.49 / $158.49 / $158.49
| Professional | TC | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $398.11 / $1,202.26
| Professional | | $371.54 | $398.11 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $194.98 / $208.93 / $645.65
| Professional | 26 | $194.98 | $208.93 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $173.78 / $190.55 / $407.38
| Professional | TC | $173.78 | $190.55 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Professional | 26 | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $416.87 / $1,288.25
| Professional | | $288.40 | $416.87 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $151.36 / $218.78 / $371.54
| Professional | 26 | $151.36 | $218.78 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $134.90 / $194.98 / $371.54
| Professional | TC | $134.90 | $194.98 | $371.54 |