- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $10.91 / $10.91 / $10.91
| Facility | 26 | $10.91 | $10.91 | $10.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.55 / $35.35 / $176.00
| Professional | | $29.55 | $35.35 | $176.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $8.46 / $10.91 / $51.00
| Professional | 26 | $8.46 | $10.91 | $51.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $20.50 / $25.28 / $47.95
| Professional | TC | $20.50 | $25.28 | $47.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.78 / $41.75 / $65.03
| Professional | | $31.78 | $41.75 | $65.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $10.32 / $13.49 / $20.39
| Professional | 26 | $10.32 | $13.49 | $20.39 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $20.92 / $28.74 / $43.73
| Professional | TC | $20.92 | $28.74 | $43.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.10 / $28.89 / $38.52
| Professional | | $22.10 | $28.89 | $38.52 |
- 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
- $50.07 / $55.70 / $67.67
| Professional | | $50.07 | $55.70 | $67.67 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $13.88 / $17.39 / $21.77
| Professional | 26 | $13.88 | $17.39 | $21.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $35.24 / $38.01 / $45.53
| Professional | TC | $35.24 | $38.01 | $45.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.72 / $33.20 / $55.20
| Professional | | $30.72 | $33.20 | $55.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $9.80 / $10.47 / $17.41
| Professional | 26 | $9.80 | $10.47 | $17.41 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $21.39 / $22.79 / $39.06
| Professional | TC | $21.39 | $22.79 | $39.06 |