- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $10.00 / $33.83
| Professional | | $10.00 | $10.00 | $33.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.75 / $19.70 / $21.63
| Professional | | $15.75 | $19.70 | $21.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.00 / $16.60 / $24.53
| Professional | | $12.00 | $16.60 | $24.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.27 / $19.48 / $27.23
| Professional | | $12.27 | $19.48 | $27.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.27 / $19.48 / $28.62
| Professional | | $12.27 | $19.48 | $28.62 |