- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $14.20 / $14.20 / $14.20
| Facility | 26 | $14.20 | $14.20 | $14.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.90 / $45.27 / $67.03
| Professional | | $39.90 | $45.27 | $67.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $10.76 / $12.36 / $27.10
| Professional | 26 | $10.76 | $12.36 | $27.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $29.08 / $32.45 / $45.75
| Professional | TC | $29.08 | $32.45 | $45.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.75 / $58.13 / $81.39
| Professional | | $45.75 | $58.13 | $81.39 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.71 / $16.88 / $22.11
| Professional | 26 | $12.71 | $16.88 | $22.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $32.70 / $40.36 / $59.31
| Professional | TC | $32.70 | $40.36 | $59.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $29.37 / $38.62
| Professional | | $23.65 | $29.37 | $38.62 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $253.98 / $253.98 / $253.98
| Facility | 26 | $253.98 | $253.98 | $253.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.23 / $66.67 / $90.51
| Professional | | $49.23 | $66.67 | $90.51 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $13.39 / $17.41 / $28.13
| Professional | 26 | $13.39 | $17.41 | $28.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $35.77 / $47.37 / $62.36
| Professional | TC | $35.77 | $47.37 | $62.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.13 / $47.20 / $72.56
| Professional | | $38.13 | $47.20 | $72.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $10.50 / $13.65 / $20.65
| Professional | 26 | $10.50 | $13.65 | $20.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $27.28 / $34.32 / $52.23
| Professional | TC | $27.28 | $34.32 | $52.23 |