- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.50 / $36.40 / $63.59
| Professional | | $17.50 | $36.40 | $63.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.00 / $117.00 / $117.00
| Professional | | $117.00 | $117.00 | $117.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.33 / $49.25 / $81.69
| Professional | | $22.33 | $49.25 | $81.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.85 / $48.96 / $109.28
| Professional | | $27.85 | $48.96 | $109.28 |