- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.53 / $57.53 / $57.53
| Facility | | $57.53 | $57.53 | $57.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.17 / $56.17 / $57.53
| Professional | | $56.17 | $56.17 | $57.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.53 / $57.53 / $57.53
| Facility | | $57.53 | $57.53 | $57.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.53 / $57.53 / $57.53
| Professional | | $57.53 | $57.53 | $57.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.40 / $56.40 / $57.53
| Professional | | $56.40 | $56.40 | $57.53 |