- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $524.81 / $1,862.09
| Professional | | $389.05 | $524.81 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $208.93 / $281.84 / $794.33
| Professional | 26 | $208.93 | $281.84 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $229.09 / $275.42 / $338.84
| Professional | TC | $229.09 | $275.42 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | 26 | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $1,949.84
| Professional | | $549.54 | $549.54 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $251.19 / $251.19 / $954.99
| Professional | 26 | $251.19 | $251.19 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Professional | TC | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $707.95 / $1,949.84
| Professional | | $630.96 | $707.95 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $302.00 / $309.03 / $954.99
| Professional | 26 | $302.00 | $309.03 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $331.13 / $380.19 / $912.01
| Professional | TC | $331.13 | $380.19 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Professional | 26 | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $691.83 / $1,819.70
| Professional | | $478.63 | $691.83 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $229.09 / $323.59 / $549.54
| Professional | 26 | $229.09 | $323.59 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $251.19 / $371.54 / $724.44
| Professional | TC | $251.19 | $371.54 | $724.44 |