- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $11.64 / $11.64 / $11.64
| Facility | 26 | $11.64 | $11.64 | $11.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.67 / $23.34 / $42.65
| Professional | | $15.67 | $23.34 | $42.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $8.75 / $10.70 / $22.86
| Professional | 26 | $8.75 | $10.70 | $22.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $6.93 / $11.48 / $15.53
| Professional | TC | $6.93 | $11.48 | $15.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.04 / $27.32 / $39.45
| Professional | | $22.04 | $27.32 | $39.45 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $10.72 / $13.77 / $21.21
| Professional | 26 | $10.72 | $13.77 | $21.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $9.86 / $12.27 / $21.46
| Professional | TC | $9.86 | $12.27 | $21.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.80 / $18.89 / $38.03
| Professional | | $7.80 | $18.89 | $38.03 |
- 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
- $27.26 / $32.90 / $41.83
| Professional | | $27.26 | $32.90 | $41.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $14.37 / $18.01 / $24.06
| Professional | 26 | $14.37 | $18.01 | $24.06 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $12.89 / $15.04 / $19.10
| Professional | TC | $12.89 | $15.04 | $19.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.48 / $21.44 / $35.39
| Professional | | $19.48 | $21.44 | $35.39 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $9.85 / $10.83 / $17.87
| Professional | 26 | $9.85 | $10.83 | $17.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $8.66 / $10.54 / $17.28
| Professional | TC | $8.66 | $10.54 | $17.28 |