- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.77 / $50.56 / $171.52
| Professional | | $20.77 | $50.56 | $171.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $205.75
| Facility | | $55.00 | $55.00 | $205.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.35 / $186.27 / $198.55
| Professional | | $93.35 | $186.27 | $198.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.87 / $36.70 / $64.37
| Facility | | $12.87 | $36.70 | $64.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.87 / $36.70 / $64.37
| Facility | | $12.87 | $36.70 | $64.37 |