- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | 26 | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $426.58 / $794.33
| Professional | | $295.12 | $426.58 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $141.25 / $269.15
| Professional | 26 | $87.10 | $141.25 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $208.93 / $302.00 / $588.84
| Professional | TC | $208.93 | $302.00 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | 26 | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $630.96 / $912.01
| Professional | | $269.15 | $630.96 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $190.55 / $275.42
| Professional | 26 | $81.28 | $190.55 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $186.21 / $436.52 / $691.83
| Professional | TC | $186.21 | $436.52 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Facility | 26 | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $645.65 / $1,412.54
| Professional | | $371.54 | $645.65 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $104.71 / $173.78 / $263.03
| Professional | 26 | $104.71 | $173.78 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $263.03 / $457.09 / $1,148.15
| Professional | TC | $263.03 | $457.09 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $501.19 / $758.58
| Professional | | $316.23 | $501.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $95.50 / $147.91 / $218.78
| Professional | 26 | $95.50 | $147.91 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $218.78 / $338.84 / $524.81
| Professional | TC | $218.78 | $338.84 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $501.19 / $912.01
| Professional | | $316.23 | $501.19 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $120.23 / $239.88
| Professional | 26 | $81.28 | $120.23 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $218.78 / $346.74 / $630.96
| Professional | TC | $218.78 | $346.74 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.70 / $63.10 / $63.10
| Facility | 26 | $53.70 | $63.10 | $63.10 |