- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.70 / $860.63 / $945.84
| Professional | | $256.70 | $860.63 | $945.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.29 / $147.25 / $161.83
| Professional | 26 | $48.29 | $147.25 | $161.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $189.86 / $713.38 / $784.01
| Professional | TC | $189.86 | $713.38 | $784.01 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.13 / $120.13 / $205.41
| Facility | 26 | $120.13 | $120.13 | $205.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.62 / $1,782.62 / $1,782.62
| Professional | | $1,782.62 | $1,782.62 | $1,782.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $313.70 / $313.70 / $313.70
| Professional | 26 | $313.70 | $313.70 | $313.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $1,468.91 / $1,468.91 / $1,468.91
| Professional | TC | $1,468.91 | $1,468.91 | $1,468.91 |