- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.44 / $30.44 / $30.44
| Facility | | $30.44 | $30.44 | $30.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.44 / $30.44 / $30.44
| Professional | | $30.44 | $30.44 | $30.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.42 / $33.42 / $33.42
| Professional | | $33.42 | $33.42 | $33.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.25 / $288.52 / $309.77
| Facility | | $245.25 | $288.52 | $309.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.74 / $35.81 / $36.89
| Professional | | $30.74 | $35.81 | $36.89 |