- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $18.48 / $18.48 / $18.48
| Facility | 26 | $18.48 | $18.48 | $18.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.31 / $46.09 / $213.00
| Professional | | $39.31 | $46.09 | $213.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $3.67 / $16.73 / $37.77
| Professional | 26 | $3.67 | $16.73 | $37.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $25.56 / $29.29 / $59.86
| Professional | TC | $25.56 | $29.29 | $59.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.99 / $55.67 / $85.89
| Professional | | $41.99 | $55.67 | $85.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $16.57 / $21.89 / $34.84
| Professional | 26 | $16.57 | $21.89 | $34.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $24.16 / $35.95 / $55.11
| Professional | TC | $24.16 | $35.95 | $55.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.48 / $28.95 / $38.52
| Professional | | $22.48 | $28.95 | $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
- $69.89 / $77.31 / $82.94
| Professional | | $69.89 | $77.31 | $82.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $24.29 / $30.43 / $36.34
| Professional | 26 | $24.29 | $30.43 | $36.34 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $39.53 / $45.60 / $50.86
| Professional | TC | $39.53 | $45.60 | $50.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.30 / $46.56 / $76.81
| Professional | | $41.30 | $46.56 | $76.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $15.40 / $17.68 / $29.40
| Professional | 26 | $15.40 | $17.68 | $29.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $25.82 / $28.88 / $47.65
| Professional | TC | $25.82 | $28.88 | $47.65 |