- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.87 / $17.55 / $37.79
| Professional | | $12.87 | $17.55 | $37.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.37 / $26.37 / $26.37
| Professional | | $26.37 | $26.37 | $26.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.73 / $23.83 / $72.00
| Professional | | $15.73 | $23.83 | $72.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.82 / $30.82 / $30.82
| Facility | 26 | $30.82 | $30.82 | $30.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.42 / $24.48 / $261.48
| Professional | | $14.42 | $24.48 | $261.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.42 / $20.81 / $50.72
| Professional | | $14.42 | $20.81 | $50.72 |