- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $10.58 / $10.58 / $10.58
| Facility | 26 | $10.58 | $10.58 | $10.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.52 / $33.47 / $155.38
| Professional | | $18.52 | $33.47 | $155.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $7.29 / $10.58 / $39.38
| Professional | 26 | $7.29 | $10.58 | $39.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $13.00 / $22.89 / $51.62
| Professional | TC | $13.00 | $22.89 | $51.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.62 / $35.39 / $58.45
| Professional | | $27.62 | $35.39 | $58.45 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $9.27 / $12.12 / $18.97
| Professional | 26 | $9.27 | $12.12 | $18.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $17.35 / $23.46 / $39.61
| Professional | TC | $17.35 | $23.46 | $39.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.02 / $28.95 / $38.62
| Professional | | $22.02 | $28.95 | $38.62 |
- 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
- $35.69 / $44.09 / $63.88
| Professional | | $35.69 | $44.09 | $63.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.89 / $16.14 / $20.44
| Professional | 26 | $12.89 | $16.14 | $20.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $22.81 / $27.95 / $43.46
| Professional | TC | $22.81 | $27.95 | $43.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.74 / $30.51 / $48.51
| Professional | | $26.74 | $30.51 | $48.51 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $8.44 / $9.38 / $15.59
| Professional | 26 | $8.44 | $9.38 | $15.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $18.36 / $21.18 / $33.38
| Professional | TC | $18.36 | $21.18 | $33.38 |