- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.78 / $53.78 / $61.84
| Facility | | $53.78 | $53.78 | $61.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.78 / $53.78 / $53.78
| Professional | | $53.78 | $53.78 | $53.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.86 / $51.86 / $51.86
| Facility | | $51.86 | $51.86 | $51.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.08 / $55.08 / $55.08
| Professional | | $55.08 | $55.08 | $55.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.30 / $54.00 / $54.00
| Professional | | $51.30 | $54.00 | $54.00 |