- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.36 / $276.37 / $1,141.00
| Professional | | $252.36 | $276.37 | $1,141.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.29 / $98.62 / $329.62
| Professional | 26 | $81.29 | $98.62 | $329.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $164.36 / $174.47 / $257.39
| Professional | TC | $164.36 | $174.47 | $257.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.35 / $334.35 / $394.12
| Professional | | $334.35 | $334.35 | $394.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.41 / $493.50 / $853.41
| Professional | | $341.41 | $493.50 | $853.41 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.40 / $171.60 / $297.05
| Professional | 26 | $117.40 | $171.60 | $297.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $201.59 / $299.98 / $366.70
| Professional | TC | $201.59 | $299.98 | $366.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.98 / $473.21 / $853.41
| Professional | | $374.98 | $473.21 | $853.41 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.40 / $170.38 / $297.05
| Professional | 26 | $117.40 | $170.38 | $297.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $201.59 / $285.20 / $340.35
| Professional | TC | $201.59 | $285.20 | $340.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.41 / $359.24 / $969.02
| Professional | | $241.41 | $359.24 | $969.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.34 / $140.36 / $350.72
| Professional | 26 | $87.34 | $140.36 | $350.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $151.93 / $217.43 / $618.29
| Professional | TC | $151.93 | $217.43 | $618.29 |