- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.50 / $289.22 / $289.22
| Professional | | $39.50 | $289.22 | $289.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.65 / $108.97 / $108.97
| Facility | | $69.65 | $108.97 | $108.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.65 / $108.97 / $108.97
| Professional | | $69.65 | $108.97 | $108.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.14 / $103.78 / $108.97
| Facility | | $51.14 | $103.78 | $108.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.65 / $81.78 / $109.04
| Professional | | $69.65 | $81.78 | $109.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.36 / $45.77 / $52.39
| Professional | | $41.36 | $45.77 | $52.39 |