- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $9.41 / $9.41 / $9.41
| Facility | 26 | $9.41 | $9.41 | $9.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.01 / $38.53 / $188.00
| Professional | | $32.01 | $38.53 | $188.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $7.53 / $14.10 / $43.00
| Professional | 26 | $7.53 | $14.10 | $43.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $25.57 / $29.99 / $62.27
| Professional | TC | $25.57 | $29.99 | $62.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.67 / $43.01 / $71.54
| Professional | | $31.67 | $43.01 | $71.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $8.90 / $11.40 / $17.55
| Professional | 26 | $8.90 | $11.40 | $17.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $22.36 / $31.60 / $53.32
| Professional | TC | $22.36 | $31.60 | $53.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.02 / $28.89 / $38.81
| Professional | | $22.02 | $28.89 | $38.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $147.24 / $147.24 / $147.24
| Facility | 26 | $147.24 | $147.24 | $147.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.02 / $62.24 / $72.40
| Professional | | $56.02 | $62.24 | $72.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $11.90 / $15.53 / $18.77
| Professional | 26 | $11.90 | $15.53 | $18.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $43.82 / $46.59 / $54.28
| Professional | TC | $43.82 | $46.59 | $54.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.72 / $36.81 / $60.74
| Professional | | $32.72 | $36.81 | $60.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $8.34 / $9.02 / $15.00
| Professional | 26 | $8.34 | $9.02 | $15.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $24.05 / $27.79 / $45.85
| Professional | TC | $24.05 | $27.79 | $45.85 |