- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $229.09 / $229.09 / $398.11
| Facility | 26 | $229.09 | $229.09 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $489.78 / $1,202.26
| Professional | | $398.11 | $489.78 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $199.53 / $380.19 / $602.56
| Professional | 26 | $199.53 | $380.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $204.17 / $263.03 / $371.54
| Professional | TC | $204.17 | $263.03 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $1,230.27
| Professional | | $831.76 | $1,023.29 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $398.11 / $489.78 / $588.84
| Professional | 26 | $398.11 | $489.78 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $436.52 / $537.03 / $645.65
| Professional | TC | $436.52 | $537.03 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $831.76 / $1,174.90
| Professional | | $588.84 | $831.76 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $269.15 / $407.38 / $537.03
| Professional | 26 | $269.15 | $407.38 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $309.03 / $436.52 / $660.69
| Professional | TC | $309.03 | $436.52 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $954.99 / $2,884.03
| Professional | | $501.19 | $954.99 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $234.42 / $446.68 / $1,412.54
| Professional | 26 | $234.42 | $446.68 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $263.03 / $524.81 / $1,479.11
| Professional | TC | $263.03 | $524.81 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $912.01 / $1,258.93
| Professional | | $467.74 | $912.01 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $223.87 / $416.87 / $588.84
| Professional | 26 | $223.87 | $416.87 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $251.19 / $489.78 / $660.69
| Professional | TC | $251.19 | $489.78 | $660.69 |