- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.48 / $68.48 / $68.48
| Professional | | $68.48 | $68.48 | $68.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.61 / $77.53 / $129.22
| Facility | | $64.61 | $77.53 | $129.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.48 / $68.48 / $129.22
| Professional | | $68.48 | $68.48 | $129.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.61 / $77.53 / $129.22
| Facility | | $64.61 | $77.53 | $129.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.48 / $68.48 / $129.22
| Professional | | $68.48 | $68.48 | $129.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.48 / $68.48 / $205.47
| Professional | | $68.48 | $68.48 | $205.47 |