- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $9.41 / $9.41 / $9.41
| Facility | 26 | $9.41 | $9.41 | $9.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.78 / $32.81 / $169.00
| Professional | | $26.78 | $32.81 | $169.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $7.24 / $9.05 / $17.98
| Professional | 26 | $7.24 | $9.05 | $17.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $19.46 / $22.89 / $48.61
| Professional | TC | $19.46 | $22.89 | $48.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.79 / $38.35 / $62.77
| Professional | | $28.79 | $38.35 | $62.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $8.82 / $11.40 / $17.55
| Professional | 26 | $8.82 | $11.40 | $17.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $19.48 / $26.95 / $45.53
| Professional | TC | $19.48 | $26.95 | $45.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.02 / $28.89 / $38.52
| Professional | | $22.02 | $28.89 | $38.52 |
- 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
- $49.57 / $55.08 / $63.60
| Professional | | $49.57 | $55.08 | $63.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $11.90 / $14.90 / $18.77
| Professional | 26 | $11.90 | $14.90 | $18.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $35.89 / $39.52 / $45.28
| Professional | TC | $35.89 | $39.52 | $45.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.76 / $32.47 / $53.59
| Professional | | $28.76 | $32.47 | $53.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $8.36 / $9.02 / $15.00
| Professional | 26 | $8.36 | $9.02 | $15.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $19.91 / $23.46 / $38.71
| Professional | TC | $19.91 | $23.46 | $38.71 |