- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.71 / $45.71 / $45.71
| Facility | | $45.71 | $45.71 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $45.71 / $45.71
| Professional | | $45.71 | $45.71 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.77 / $79.43 / $83.18
| Facility | | $46.77 | $79.43 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $60.26 / $64.57
| Professional | | $57.54 | $60.26 | $64.57 |