- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.42 / $48.56 / $48.56
| Professional | | $39.42 | $48.56 | $48.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.75 / $251.75 / $251.75
| Facility | | $251.75 | $251.75 | $251.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.56 / $48.56 / $251.75
| Professional | | $48.56 | $48.56 | $251.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.75 / $251.75 / $251.75
| Facility | | $251.75 | $251.75 | $251.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.56 / $48.56 / $251.75
| Professional | | $48.56 | $48.56 | $251.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.13 / $57.13 / $171.39
| Professional | | $57.13 | $57.13 | $171.39 |