- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.30 / $597.30 / $751.08
| Professional | | $597.30 | $597.30 | $751.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $102.20 / $102.20 / $128.51
| Professional | 26 | $102.20 | $102.20 | $128.51 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $495.12 / $495.12 / $622.57
| Professional | TC | $495.12 | $495.12 | $622.57 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $51.82 / $57.43 / $117.28
| Facility | 26 | $51.82 | $57.43 | $117.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.04 / $983.04 / $983.04
| Professional | | $983.04 | $983.04 | $983.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $800.73 / $800.73 / $800.73
| Professional | TC | $800.73 | $800.73 | $800.73 |