- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $8.65 / $8.65 / $8.65
| Facility | 26 | $8.65 | $8.65 | $8.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.51 / $26.10 / $114.12
| Professional | | $20.51 | $26.10 | $114.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $6.45 / $8.65 / $17.16
| Professional | 26 | $6.45 | $8.65 | $17.16 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $14.08 / $17.45 / $37.29
| Professional | TC | $14.08 | $17.45 | $37.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.68 / $29.69 / $51.67
| Professional | | $23.68 | $29.69 | $51.67 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $8.11 / $10.33 / $16.82
| Professional | 26 | $8.11 | $10.33 | $16.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $15.16 / $19.27 / $34.84
| Professional | TC | $15.16 | $19.27 | $34.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.02 / $28.82 / $38.52
| Professional | | $22.02 | $28.82 | $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
- $36.19 / $41.54 / $48.91
| Professional | | $36.19 | $41.54 | $48.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $11.40 / $14.28 / $16.54
| Professional | 26 | $11.40 | $14.28 | $16.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $24.79 / $27.54 / $32.35
| Professional | TC | $24.79 | $27.54 | $32.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.20 / $24.54 / $40.79
| Professional | | $22.20 | $24.54 | $40.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $7.48 / $8.30 / $13.80
| Professional | 26 | $7.48 | $8.30 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $14.62 / $16.30 / $27.09
| Professional | TC | $14.62 | $16.30 | $27.09 |