- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.95 / $60.26 / $72.44
| Professional | | $19.95 | $60.26 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $75.86 / $75.86
| Professional | | $56.23 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $109.65 / $1,000.00
| Professional | | $95.50 | $109.65 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.89 / $5.89 / $6.03
| Facility | | $5.89 | $5.89 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $162.18 / $162.18
| Professional | | $128.82 | $162.18 | $162.18 |