- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $7.02 / $8.00 / $25.08
| Facility | 26 | $7.02 | $8.00 | $25.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $5.82 / $7.52 / $26.13
| Professional | 26 | $5.82 | $7.52 | $26.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $19.55 / $22.77 / $78.81
| Professional | TC | $19.55 | $22.77 | $78.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $24.23 / $28.50 / $31.92
| Professional | 26 | $24.23 | $28.50 | $31.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $10.48 / $12.34 / $17.76
| Professional | 26 | $10.48 | $12.34 | $17.76 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $13.35 / $15.71 / $22.96
| Professional | TC | $13.35 | $15.71 | $22.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.15 / $28.15 / $28.15
| Facility | 26 | $28.15 | $28.15 | $28.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $23.46 / $33.84 / $71.64
| Professional | 26 | $23.46 | $33.84 | $71.64 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $67.75 / $100.60 / $231.82
| Professional | TC | $67.75 | $100.60 | $231.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.28 / $27.86 / $31.83
| Professional | 26 | $20.28 | $27.86 | $31.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $57.76 / $84.48 / $101.17
| Professional | TC | $57.76 | $84.48 | $101.17 |