- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $363.08 / $1,445.44
| Facility | | $134.90 | $363.08 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $58.88 / $67.61
| Facility | 26 | $58.88 | $58.88 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $134.90 / $549.54
| Professional | | $109.65 | $134.90 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $173.78 / $478.63
| Professional | 26 | $57.54 | $173.78 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $61.66 / $75.86 / $346.74
| Professional | TC | $61.66 | $75.86 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $104.71 / $331.13
| Professional | | $67.61 | $104.71 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.88 / $46.77 / $186.21
| Professional | 26 | $33.88 | $46.77 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $33.11 / $58.88 / $144.54
| Professional | TC | $33.11 | $58.88 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $151.36
| Professional | | $144.54 | $144.54 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | 26 | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $125.89 / $354.81
| Professional | | $83.18 | $125.89 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $44.67 / $70.79 / $165.96
| Professional | 26 | $44.67 | $70.79 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $44.67 / $72.44 / $186.21
| Professional | TC | $44.67 | $72.44 | $186.21 |