- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $165.96 / $338.84
| Professional | | $123.03 | $165.96 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.66 / $52.48 / $154.88
| Professional | 26 | $42.66 | $52.48 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $83.18 / $112.20 / $177.83
| Professional | TC | $83.18 | $112.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $288.40 / $288.40
| Professional | | $245.47 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $288.40 / $501.19
| Professional | | $144.54 | $288.40 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.66 / $89.13 / $154.88
| Professional | 26 | $42.66 | $89.13 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $102.33 / $199.53 / $281.84
| Professional | TC | $102.33 | $199.53 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $144.54 / $501.19
| Professional | | $141.25 | $144.54 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $43.65 / $47.86 / $154.88
| Professional | 26 | $43.65 | $47.86 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $97.72 / $97.72 / $158.49
| Professional | TC | $97.72 | $97.72 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $199.53 / $354.81
| Professional | | $144.54 | $199.53 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $45.71 / $64.57 / $104.71
| Professional | 26 | $45.71 | $64.57 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $97.72 / $138.04 / $218.78
| Professional | TC | $97.72 | $138.04 | $218.78 |