- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.20 / $31.42 / $32.86
| Professional | | $20.20 | $31.42 | $32.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.00 / $65.00 / $152.75
| Professional | | $65.00 | $65.00 | $152.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.87 / $46.87 / $46.87
| Professional | | $46.87 | $46.87 | $46.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $62.67 / $85.00 / $168.77
| Facility | | $62.67 | $85.00 | $168.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.34 / $227.41 / $260.25
| Professional | | $221.34 | $227.41 | $260.25 |