- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $21.48 / $21.48 / $21.48
| Facility | 26 | $21.48 | $21.48 | $21.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.77 / $31.46 / $56.53
| Professional | | $17.77 | $31.46 | $56.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $13.30 / $24.21 / $43.03
| Professional | 26 | $13.30 | $24.21 | $43.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $4.47 / $7.25 / $16.38
| Professional | TC | $4.47 | $7.25 | $16.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $19.60 / $19.60 / $22.01
| Professional | 26 | $19.60 | $19.60 | $22.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.80 / $35.46 / $50.30
| Professional | | $25.80 | $35.46 | $50.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.05 / $25.74 / $39.47
| Professional | 26 | $20.05 | $25.74 | $39.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $5.75 / $9.16 / $10.82
| Professional | TC | $5.75 | $9.16 | $10.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $19.14 / $19.14 / $19.14
| Professional | 26 | $19.14 | $19.14 | $19.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.51 / $18.98 / $59.46
| Professional | | $13.51 | $18.98 | $59.46 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $9.80 / $15.04 / $42.62
| Professional | 26 | $9.80 | $15.04 | $42.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $3.17 / $3.95 / $14.00
| Professional | TC | $3.17 | $3.95 | $14.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.48 / $30.32 / $55.53
| Professional | | $17.48 | $30.32 | $55.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $13.36 / $23.10 / $42.73
| Professional | 26 | $13.36 | $23.10 | $42.73 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $4.00 / $7.30 / $12.80
| Professional | TC | $4.00 | $7.30 | $12.80 |