- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.07 / $33.97 / $60.56
| Professional | | $22.07 | $33.97 | $60.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.50 / $52.18 / $69.58
| Professional | | $26.50 | $52.18 | $69.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.65 / $25.65 / $25.65
| Professional | | $25.65 | $25.65 | $25.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.77 / $73.77 / $73.77
| Professional | | $73.77 | $73.77 | $73.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.22 / $26.66 / $38.67
| Professional | | $22.22 | $26.66 | $38.67 |