- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $295.12 / $512.86
| Professional | | $186.21 | $295.12 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $154.88 / $251.19 / $407.38
| Professional | TC | $154.88 | $251.19 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Facility | 26 | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $346.74 / $891.25
| Professional | | $295.12 | $346.74 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $234.42 / $281.84 / $602.56
| Professional | TC | $234.42 | $281.84 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $371.54 / $933.25
| Professional | | $239.88 | $371.54 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $190.55 / $302.00 / $512.86
| Professional | TC | $190.55 | $302.00 | $512.86 |