- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $18.39 / $34.20
| Professional | | $10.00 | $18.39 | $34.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.35 / $15.35 / $22.55
| Professional | | $15.35 | $15.35 | $22.55 |
- 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
- $12.40 / $17.73 / $28.66
| Professional | | $12.40 | $17.73 | $28.66 |