- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $13.21 / $13.21 / $13.21
| Facility | 26 | $13.21 | $13.21 | $13.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.67 / $56.04 / $203.17
| Professional | | $35.67 | $56.04 | $203.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $9.65 / $12.02 / $22.87
| Professional | 26 | $9.65 | $12.02 | $22.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $25.28 / $42.83 / $67.95
| Professional | TC | $25.28 | $42.83 | $67.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.32 / $57.78 / $86.12
| Professional | | $46.32 | $57.78 | $86.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $11.44 / $15.24 / $23.40
| Professional | 26 | $11.44 | $15.24 | $23.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $33.11 / $42.76 / $62.72
| Professional | TC | $33.11 | $42.76 | $62.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.10 / $29.37 / $39.23
| Professional | | $22.10 | $29.37 | $39.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $198.33 / $198.33 / $198.33
| Facility | 26 | $198.33 | $198.33 | $198.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.48 / $75.76 / $81.73
| Professional | | $60.48 | $75.76 | $81.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $15.87 / $19.87 / $25.78
| Professional | 26 | $15.87 | $19.87 | $25.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $44.61 / $52.42 / $60.13
| Professional | TC | $44.61 | $52.42 | $60.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.06 / $44.93 / $74.16
| Professional | | $40.06 | $44.93 | $74.16 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $10.98 / $11.89 / $19.64
| Professional | 26 | $10.98 | $11.89 | $19.64 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $28.51 / $35.95 / $48.46
| Professional | TC | $28.51 | $35.95 | $48.46 |