- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.20 / $30.33 / $47.50
| Professional | | $18.20 | $30.33 | $47.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.00 / $52.00 / $100.00
| Professional | | $34.00 | $52.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $51.00 / $93.00 / $150.00
| Professional | 50 | $51.00 | $93.00 | $150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.82 / $45.13 / $77.38
| Professional | | $26.82 | $45.13 | $77.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.00 / $76.26 / $162.50
| Professional | | $56.00 | $76.26 | $162.50 |