- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.25 / $53.25 / $60.86
| Facility | | $53.25 | $53.25 | $60.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.72 / $53.25 / $60.86
| Professional | | $50.72 | $53.25 | $60.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.50 / $103.50 / $103.50
| Professional | | $103.50 | $103.50 | $103.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.71 / $50.71 / $50.71
| Facility | | $50.71 | $50.71 | $50.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.71 / $50.71 / $50.71
| Professional | | $50.71 | $50.71 | $50.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.18 / $50.72 / $65.94
| Professional | | $48.18 | $50.72 | $65.94 |