- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $14.93 / $17.52 / $17.52
| Facility | 26 | $14.93 | $17.52 | $17.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.97 / $42.43 / $73.48
| Professional | | $39.97 | $42.43 | $73.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.08 / $12.10 / $19.71
| Professional | 26 | $12.08 | $12.10 | $19.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $27.87 / $30.35 / $53.78
| Professional | TC | $27.87 | $30.35 | $53.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.52 / $46.54 / $86.63
| Professional | | $34.52 | $46.54 | $86.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $9.44 / $14.56 / $24.16
| Professional | 26 | $9.44 | $14.56 | $24.16 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $21.35 / $33.45 / $62.14
| Professional | TC | $21.35 | $33.45 | $62.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.97 / $54.97 / $54.97
| Professional | | $54.97 | $54.97 | $54.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.47 / $12.47 / $12.47
| Professional | 26 | $12.47 | $12.47 | $12.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.68 / $50.73 / $104.08
| Professional | | $36.68 | $50.73 | $104.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $10.74 / $15.61 / $31.56
| Professional | 26 | $10.74 | $15.61 | $31.56 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $26.27 / $34.61 / $73.76
| Professional | TC | $26.27 | $34.61 | $73.76 |