- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.91 / $65.91 / $65.91
| Professional | | $65.91 | $65.91 | $65.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.24 / $108.14 / $178.62
| Facility | | $39.24 | $108.14 | $178.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.38 / $100.38 / $105.46
| Facility | | $100.38 | $100.38 | $105.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.77 / $65.91 / $105.46
| Facility | | $37.77 | $65.91 | $105.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.34 / $13.34 / $18.01
| Professional | | $13.34 | $13.34 | $18.01 |