- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.13 / $706.60 / $957.01
| Professional | | $454.13 | $706.60 | $957.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $77.70 / $120.90 / $163.74
| Professional | 26 | $77.70 | $120.90 | $163.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $376.43 / $585.70 / $793.27
| Professional | TC | $376.43 | $585.70 | $793.27 |
- 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 |