- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $18.60 / $18.60 / $18.60
| Facility | 26 | $18.60 | $18.60 | $18.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.40 / $54.64 / $76.50
| Professional | | $38.40 | $54.64 | $76.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $11.63 / $15.57 / $21.70
| Professional | 26 | $11.63 | $15.57 | $21.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $26.49 / $39.26 / $54.80
| Professional | TC | $26.49 | $39.26 | $54.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.62 / $72.05 / $94.13
| Professional | | $47.62 | $72.05 | $94.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $16.30 / $22.21 / $33.54
| Professional | 26 | $16.30 | $22.21 | $33.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $32.47 / $50.34 / $64.23
| Professional | TC | $32.47 | $50.34 | $64.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.14 / $28.98 / $38.52
| Professional | | $22.14 | $28.98 | $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
- $73.73 / $98.46 / $126.51
| Professional | | $73.73 | $98.46 | $126.51 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.73 / $30.17 / $39.86
| Professional | 26 | $22.73 | $30.17 | $39.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $51.25 / $68.23 / $87.97
| Professional | TC | $51.25 | $68.23 | $87.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.80 / $58.10 / $86.65
| Professional | | $43.80 | $58.10 | $86.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.90 / $17.39 / $22.95
| Professional | 26 | $12.90 | $17.39 | $22.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $30.90 / $40.17 / $55.03
| Professional | TC | $30.90 | $40.17 | $55.03 |