- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $630.96 / $1,949.84
| Professional | | $389.05 | $630.96 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $89.13 / $281.84
| Professional | 26 | $57.54 | $89.13 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $331.13 / $478.63 / $691.83
| Professional | TC | $331.13 | $478.63 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Facility | 26 | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $1,862.09
| Professional | | $602.56 | $602.56 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $102.33 / $102.33 / $316.23
| Professional | 26 | $102.33 | $102.33 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | TC | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $660.69 / $1,862.09
| Professional | | $616.60 | $660.69 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $109.65 / $316.23
| Professional | 26 | $107.15 | $109.65 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $501.19 / $562.34 / $1,348.96
| Professional | TC | $501.19 | $562.34 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $912.01 / $1,995.26
| Professional | | $549.54 | $912.01 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.50 / $165.96 / $251.19
| Professional | 26 | $95.50 | $165.96 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $436.52 / $741.31 / $1,096.48
| Professional | TC | $436.52 | $741.31 | $1,096.48 |