- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $281.84 / $537.03
| Professional | | $239.88 | $281.84 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $102.33 / $181.97
| Professional | 26 | $89.13 | $102.33 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $144.54 / $186.21 / $380.19
| Professional | TC | $144.54 | $186.21 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $251.19 / $645.65
| Professional | | $190.55 | $251.19 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $117.49 / $190.55
| Professional | 26 | $87.10 | $117.49 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $87.10 / $165.96 / $489.78
| Professional | TC | $87.10 | $165.96 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $263.03 / $588.84
| Professional | | $199.53 | $263.03 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $120.23 / $234.42
| Professional | 26 | $81.28 | $120.23 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $85.11 / $158.49 / $346.74
| Professional | TC | $85.11 | $158.49 | $346.74 |