- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $6.15 / $8.30 / $15.80
| Facility | 26 | $6.15 | $8.30 | $15.80 |
- Facility/Professional
- Facility
- Modifier
- TC
- Low / Median / High Price
- $22.33 / $29.44 / $287.00
| Facility | TC | $22.33 | $29.44 | $287.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.37 / $28.48 / $66.48
| Professional | | $25.37 | $28.48 | $66.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $5.53 / $5.87 / $9.81
| Professional | 26 | $5.53 | $5.87 | $9.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $19.64 / $22.33 / $30.38
| Professional | TC | $19.64 | $22.33 | $30.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.05 / $29.24 / $53.05
| Professional | | $20.05 | $29.24 | $53.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $4.63 / $6.89 / $11.45
| Professional | 26 | $4.63 | $6.89 | $11.45 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $14.05 / $22.35 / $41.60
| Professional | TC | $14.05 | $22.35 | $41.60 |
- Facility/Professional
- Facility
- Modifier
- TC
- Low / Median / High Price
- $263.00 / $263.00 / $263.00
| Facility | TC | $263.00 | $263.00 | $263.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.81 / $26.81 / $36.70
| Professional | | $26.81 | $26.81 | $36.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $5.86 / $8.00 / $61.12
| Professional | 26 | $5.86 | $8.00 | $61.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $21.20 / $21.20 / $21.20
| Professional | TC | $21.20 | $21.20 | $21.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.13 / $29.04 / $63.89
| Professional | | $22.13 | $29.04 | $63.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $4.98 / $6.93 / $14.99
| Professional | 26 | $4.98 | $6.93 | $14.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $17.12 / $21.00 / $47.82
| Professional | TC | $17.12 | $21.00 | $47.82 |