- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $8.85 / $10.48 / $24.62
| Professional | 26 | $8.85 | $10.48 | $24.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $13.83 / $16.50 / $35.69
| Professional | TC | $13.83 | $16.50 | $35.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.61 / $29.75 / $42.52
| Professional | 26 | $23.61 | $29.75 | $42.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $34.32 / $43.24 / $67.48
| Professional | TC | $34.32 | $43.24 | $67.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $17.38 / $29.07 / $68.50
| Professional | 26 | $17.38 | $29.07 | $68.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $26.58 / $44.55 / $110.30
| Professional | TC | $26.58 | $44.55 | $110.30 |