- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.22 / $53.22 / $53.22
| Facility | | $53.22 | $53.22 | $53.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.22 / $53.22 / $53.22
| Professional | | $53.22 | $53.22 | $53.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.04 / $23.48 / $40.27
| Professional | | $11.04 | $23.48 | $40.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $40.00
| Professional | | $17.00 | $20.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.16 / $13.27 / $35.86
| Professional | | $10.16 | $13.27 | $35.86 |