- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.83 / $297.92 / $297.92
| Professional | | $296.83 | $297.92 | $297.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $151.16 / $156.56 / $156.56
| Professional | 26 | $151.16 | $156.56 | $156.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $141.36 / $141.36 / $145.68
| Professional | TC | $141.36 | $141.36 | $145.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.98 / $332.98 / $1,211.41
| Professional | | $332.98 | $332.98 | $1,211.41 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $177.03 / $177.03 / $640.90
| Professional | 26 | $177.03 | $177.03 | $640.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $159.35 / $159.35 / $159.35
| Professional | TC | $159.35 | $159.35 | $159.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.59 / $400.74 / $1,211.41
| Professional | | $385.59 | $400.74 | $1,211.41 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $202.93 / $206.69 / $640.90
| Professional | 26 | $202.93 | $206.69 | $640.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $182.66 / $191.98 / $309.66
| Professional | TC | $182.66 | $191.98 | $309.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.59 / $400.74 / $1,211.41
| Professional | | $385.59 | $400.74 | $1,211.41 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $202.93 / $206.69 / $640.90
| Professional | 26 | $202.93 | $206.69 | $640.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $175.26 / $191.98 / $309.66
| Professional | TC | $175.26 | $191.98 | $309.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $422.88 / $661.61
| Professional | | $286.94 | $422.88 | $661.61 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $151.51 / $217.83 / $350.03
| Professional | 26 | $151.51 | $217.83 | $350.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $135.43 / $194.50 / $606.87
| Professional | TC | $135.43 | $194.50 | $606.87 |