- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.70 / $37.67 / $57.00
| Professional | | $10.70 | $37.67 | $57.00 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $37.67 / $37.67 / $37.67
| Professional | 25 | $37.67 | $37.67 | $37.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.07 / $42.86 / $52.59
| Professional | | $42.07 | $42.86 | $52.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.45 / $14.21 / $50.15
| Professional | | $13.45 | $14.21 | $50.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.05 / $34.83 / $48.49
| Professional | | $23.05 | $34.83 | $48.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.45 / $18.85 / $33.06
| Professional | | $13.45 | $18.85 | $33.06 |