- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $7.94 / $10.00 / $30.20
| Professional | 26 | $7.94 | $10.00 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $19.05 / $26.92 / $69.18
| Professional | TC | $19.05 | $26.92 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $9.33 / $15.14 / $77.62
| Professional | 26 | $9.33 | $15.14 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $23.99 / $38.02 / $302.00
| Professional | TC | $23.99 | $38.02 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.30 / $20.89 / $28.18
| Professional | 26 | $12.30 | $20.89 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $9.33 / $16.22 / $31.62
| Professional | 26 | $9.33 | $16.22 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $22.91 / $41.69 / $77.62
| Professional | TC | $22.91 | $41.69 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $10.72 / $15.85 / $28.18
| Professional | 26 | $10.72 | $15.85 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $26.92 / $40.74 / $75.86
| Professional | TC | $26.92 | $40.74 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $9.33 / $15.14 / $77.62
| Professional | 26 | $9.33 | $15.14 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $23.99 / $38.02 / $302.00
| Professional | TC | $23.99 | $38.02 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $10.47 / $15.14 / $28.84
| Professional | 26 | $10.47 | $15.14 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $25.70 / $37.15 / $72.44
| Professional | TC | $25.70 | $37.15 | $72.44 |