- 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
- $36.19 / $45.27 / $63.23
| Professional | | $36.19 | $45.27 | $63.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $11.06 / $12.62 / $17.22
| Professional | 26 | $11.06 | $12.62 | $17.22 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $25.06 / $31.13 / $40.29
| Professional | TC | $25.06 | $31.13 | $40.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.28 / $55.81 / $80.79
| Professional | | $43.28 | $55.81 | $80.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.71 / $17.05 / $22.71
| Professional | 26 | $12.71 | $17.05 | $22.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $31.08 / $38.34 / $58.11
| Professional | TC | $31.08 | $38.34 | $58.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.34 / $29.37 / $38.62
| Professional | | $23.34 | $29.37 | $38.62 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $481.30 / $481.30 / $481.30
| Facility | 26 | $481.30 | $481.30 | $481.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.05 / $61.19 / $86.77
| Professional | | $48.05 | $61.19 | $86.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $13.77 / $17.91 / $28.88
| Professional | 26 | $13.77 | $17.91 | $28.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $33.09 / $42.36 / $57.88
| Professional | TC | $33.09 | $42.36 | $57.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.45 / $47.15 / $68.25
| Professional | | $36.45 | $47.15 | $68.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $11.16 / $14.76 / $20.52
| Professional | 26 | $11.16 | $14.76 | $20.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $25.66 / $32.39 / $45.29
| Professional | TC | $25.66 | $32.39 | $45.29 |