- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $14.29 / $14.29 / $14.29
| Facility | 26 | $14.29 | $14.29 | $14.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.90 / $47.95 / $231.00
| Professional | | $39.90 | $47.95 | $231.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $11.17 / $14.29 / $65.00
| Professional | 26 | $11.17 | $14.29 | $65.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $29.50 / $34.33 / $173.00
| Professional | TC | $29.50 | $34.33 | $173.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.72 / $55.61 / $91.08
| Professional | | $41.72 | $55.61 | $91.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $13.24 / $17.13 / $26.76
| Professional | 26 | $13.24 | $17.13 | $26.76 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $27.75 / $38.85 / $62.90
| Professional | TC | $27.75 | $38.85 | $62.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.14 / $28.95 / $38.81
| Professional | | $22.14 | $28.95 | $38.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $198.33 / $198.33 / $198.33
| Facility | 26 | $198.33 | $198.33 | $198.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.39 / $78.51 / $91.28
| Professional | | $70.39 | $78.51 | $91.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $18.34 / $22.98 / $28.46
| Professional | 26 | $18.34 | $22.98 | $28.46 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $51.76 / $55.02 / $64.06
| Professional | TC | $51.76 | $55.02 | $64.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.90 / $46.56 / $76.81
| Professional | | $41.90 | $46.56 | $76.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.34 / $13.71 / $22.69
| Professional | 26 | $12.34 | $13.71 | $22.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $29.56 / $32.85 / $54.20
| Professional | TC | $29.56 | $32.85 | $54.20 |