- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $92.98 / $92.98
| Professional | | $89.41 | $92.98 | $92.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $89.41 / $93.11
| Professional | | $89.41 | $89.41 | $93.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.41 / $89.41 / $89.41
| Facility | | $89.41 | $89.41 | $89.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $89.41 / $89.41
| Professional | | $89.41 | $89.41 | $89.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $89.41 / $89.41
| Professional | | $89.41 | $89.41 | $89.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $92.98 / $92.98
| Professional | | $89.41 | $92.98 | $92.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $89.41 / $129.63
| Professional | | $89.41 | $89.41 | $129.63 |