- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.74 / $52.74 / $52.74
| Facility | | $52.74 | $52.74 | $52.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.72 / $50.72 / $52.74
| Professional | | $50.72 | $50.72 | $52.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.84 / $50.71 / $50.71
| Facility | | $47.84 | $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
- $50.72 / $50.72 / $50.72
| Professional | | $50.72 | $50.72 | $50.72 |