- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $31.62 / $31.62 / $31.62
| Facility | 26 | $31.62 | $31.62 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $114.82 / $208.93
| Professional | | $70.79 | $114.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.89 / $34.67 / $109.65
| Professional | 26 | $20.89 | $34.67 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $46.77 / $79.43 / $147.91
| Professional | TC | $46.77 | $79.43 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $144.54 / $151.36
| Professional | | $81.28 | $144.54 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.84 / $38.90 / $44.67
| Professional | 26 | $28.84 | $38.90 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $52.48 / $104.71 / $112.20
| Professional | TC | $52.48 | $104.71 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $31.62 / $31.62 / $31.62
| Professional | 26 | $31.62 | $31.62 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $57.54 / $199.53
| Professional | | $39.81 | $57.54 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.30 / $16.98 / $57.54
| Professional | 26 | $12.30 | $16.98 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $21.38 / $42.66 / $144.54
| Professional | TC | $21.38 | $42.66 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $107.15 / $194.98
| Professional | | $57.54 | $107.15 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $15.85 / $33.88 / $58.88
| Professional | 26 | $15.85 | $33.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $29.51 / $75.86 / $147.91
| Professional | TC | $29.51 | $75.86 | $147.91 |