- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.75 / $52.75 / $135.85
| Professional | | $52.75 | $52.75 | $135.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.77 / $58.63 / $97.71
| Facility | | $49.77 | $58.63 | $97.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.75 / $52.75 / $97.71
| Professional | | $52.75 | $52.75 | $97.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.77 / $58.63 / $97.71
| Facility | | $49.77 | $58.63 | $97.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.75 / $52.75 / $97.71
| Professional | | $52.75 | $52.75 | $97.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.75 / $52.75 / $158.25
| Professional | | $52.75 | $52.75 | $158.25 |