- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.59 / $952.20 / $1,814.24
| Facility | | $245.59 | $952.20 | $1,814.24 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $68.98 / $68.98 / $79.95
| Facility | 26 | $68.98 | $68.98 | $79.95 |
- Facility/Professional
- Facility
- Modifier
- TC
- Low / Median / High Price
- $176.61 / $176.61 / $207.84
| Facility | TC | $176.61 | $176.61 | $207.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.40 / $198.93 / $245.59
| Professional | | $182.40 | $198.93 | $245.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.86 / $67.76 / $68.98
| Professional | 26 | $50.86 | $67.76 | $68.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $131.18 / $131.54 / $176.61
| Professional | TC | $131.18 | $131.54 | $176.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.29 / $201.60 / $448.68
| Professional | | $103.29 | $201.60 | $448.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $39.25 / $54.88 / $214.18
| Professional | 26 | $39.25 | $54.88 | $214.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $64.03 / $122.56 / $279.70
| Professional | TC | $64.03 | $122.56 | $279.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.16 / $251.16 / $251.16
| Professional | | $251.16 | $251.16 | $251.16 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $68.90 / $68.90 / $69.58
| Professional | 26 | $68.90 | $68.90 | $69.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.09 / $225.20 / $630.41
| Professional | | $147.09 | $225.20 | $630.41 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $51.60 / $83.20 / $192.68
| Professional | 26 | $51.60 | $83.20 | $192.68 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $100.25 / $189.02 / $437.73
| Professional | TC | $100.25 | $189.02 | $437.73 |