- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.55 / $54.55 / $54.55
| Facility | | $54.55 | $54.55 | $54.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.55 / $54.55 / $54.55
| Professional | | $54.55 | $54.55 | $54.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.81 / $59.81 / $59.81
| Professional | | $59.81 | $59.81 | $59.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.55 / $54.55 / $54.55
| Facility | | $54.55 | $54.55 | $54.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.34 / $56.42 / $91.44
| Professional | | $51.34 | $56.42 | $91.44 |