- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.41 / $65.41 / $65.41
| Facility | | $65.41 | $65.41 | $65.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.22 / $65.41 / $65.41
| Professional | | $33.22 | $65.41 | $65.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.92 / $57.92 / $57.92
| Professional | | $57.92 | $57.92 | $57.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.03 / $37.03 / $59.25
| Facility | | $37.03 | $37.03 | $59.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.03 / $37.03 / $57.67
| Professional | | $27.03 | $37.03 | $57.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.71 / $38.82 / $48.53
| Professional | | $19.71 | $38.82 | $48.53 |