- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $6.36 / $6.36 / $6.36
| Facility | 26 | $6.36 | $6.36 | $6.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.87 / $23.37 / $32.63
| Professional | | $13.87 | $23.37 | $32.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $2.75 / $4.87 / $6.45
| Professional | 26 | $2.75 | $4.87 | $6.45 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $11.11 / $18.37 / $24.67
| Professional | TC | $11.11 | $18.37 | $24.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.11 / $27.58 / $34.82
| Professional | | $17.11 | $27.58 | $34.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $3.18 / $5.91 / $8.80
| Professional | 26 | $3.18 | $5.91 | $8.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $13.96 / $20.51 / $27.18
| Professional | TC | $13.96 | $20.51 | $27.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.23 / $38.07 / $60.00
| Professional | | $10.23 | $38.07 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $101.30 / $101.30 / $101.30
| Facility | 26 | $101.30 | $101.30 | $101.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.17 / $23.54 / $52.78
| Professional | | $17.17 | $23.54 | $52.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $3.06 / $4.71 / $12.91
| Professional | 26 | $3.06 | $4.71 | $12.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $13.83 / $18.84 / $39.90
| Professional | TC | $13.83 | $18.84 | $39.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.80 / $24.14 / $37.18
| Professional | | $18.80 | $24.14 | $37.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $3.48 / $5.45 / $7.84
| Professional | 26 | $3.48 | $5.45 | $7.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $14.50 / $19.00 / $29.68
| Professional | TC | $14.50 | $19.00 | $29.68 |