- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $52.50
| Facility | | $40.00 | $40.00 | $52.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.36 / $35.69 / $55.72
| Professional | | $24.36 | $35.69 | $55.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.77 / $39.22 / $50.96
| Professional | | $30.77 | $39.22 | $50.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.00 / $37.00 / $70.00
| Professional | | $27.00 | $37.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.15 / $43.06 / $60.86
| Professional | | $32.15 | $43.06 | $60.86 |