- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $61.66 / $112.20
| Professional | | $34.67 | $61.66 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Professional | 25 | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $50.12 / $87.10
| Professional | | $26.92 | $50.12 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $87.10 / $190.55
| Professional | | $50.12 | $87.10 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $95.50 / $223.87
| Professional | | $41.69 | $95.50 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $72.44 / $173.78
| Professional | | $38.02 | $72.44 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $57.54
| Professional | | $57.54 | $57.54 | $57.54 |