- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $24.16 / $24.16 / $24.16
| Facility | 26 | $24.16 | $24.16 | $24.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.84 / $46.66 / $74.56
| Professional | | $32.84 | $46.66 | $74.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $17.14 / $22.42 / $29.98
| Professional | 26 | $17.14 | $22.42 | $29.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $11.12 / $27.84 / $45.10
| Professional | TC | $11.12 | $27.84 | $45.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.45 / $53.94 / $97.10
| Professional | | $39.45 | $53.94 | $97.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.05 / $29.99 / $48.29
| Professional | 26 | $23.05 | $29.99 | $48.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $11.80 / $27.69 / $55.19
| Professional | TC | $11.80 | $27.69 | $55.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.14 / $28.89 / $38.52
| Professional | | $22.14 | $28.89 | $38.52 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $67.61 / $67.61
| Facility | 26 | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.55 / $79.76 / $112.44
| Professional | | $63.55 | $79.76 | $112.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.00 / $43.14 / $54.23
| Professional | 26 | $33.00 | $43.14 | $54.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $19.01 / $23.81 / $69.31
| Professional | TC | $19.01 | $23.81 | $69.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.26 / $45.42 / $69.34
| Professional | | $30.26 | $45.42 | $69.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $18.60 / $25.29 / $36.81
| Professional | 26 | $18.60 | $25.29 | $36.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $9.60 / $23.76 / $38.63
| Professional | TC | $9.60 | $23.76 | $38.63 |