- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.22 / $55.28 / $58.83
| Professional | | $51.22 | $55.28 | $58.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $62.35 / $62.35 / $62.35
| Facility | | $62.35 | $62.35 | $62.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.71 / $62.35 / $62.35
| Professional | | $50.71 | $62.35 | $62.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.72 / $57.91 / $62.35
| Facility | | $50.72 | $57.91 | $62.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.02 / $55.02 / $71.76
| Professional | | $55.02 | $55.02 | $71.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.72 / $50.72 / $50.72
| Professional | | $50.72 | $50.72 | $50.72 |