- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.36 / $32.36 / $32.36
| Facility | 26 | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.15 / $72.44 / $134.90
| Professional | | $37.15 | $72.44 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $19.05 / $40.74 / $77.62
| Professional | 26 | $19.05 | $40.74 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $15.85 / $21.88 / $50.12
| Professional | TC | $15.85 | $21.88 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $38.02 / $60.26
| Professional | | $33.11 | $38.02 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.91 / $27.54 / $34.67
| Professional | 26 | $22.91 | $27.54 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $27.54 / $27.54 / $28.84
| Professional | TC | $27.54 | $27.54 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $77.62 / $85.11
| Professional | | $36.31 | $77.62 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $18.20 / $24.55 / $27.54
| Professional | 26 | $18.20 | $24.55 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $16.22 / $52.48 / $57.54
| Professional | TC | $16.22 | $52.48 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $26.92 / $26.92 / $26.92
| Facility | 26 | $26.92 | $26.92 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.48 / $58.88 / $125.89
| Professional | | $35.48 | $58.88 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.39 / $31.62 / $66.07
| Professional | 26 | $22.39 | $31.62 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $19.05 / $28.84 / $72.44
| Professional | TC | $19.05 | $28.84 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $45.71 / $87.10
| Professional | | $34.67 | $45.71 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $19.05 / $24.55 / $34.67
| Professional | 26 | $19.05 | $24.55 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $15.49 / $20.89 / $53.70
| Professional | TC | $15.49 | $20.89 | $53.70 |