- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.75 / $48.75 / $48.75
| Facility | | $48.75 | $48.75 | $48.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.57 / $48.75 / $51.58
| Professional | | $45.57 | $48.75 | $51.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.00 / $51.00 / $115.43
| Professional | | $51.00 | $51.00 | $115.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.91 / $58.59 / $138.44
| Professional | | $47.91 | $58.59 | $138.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.92 / $58.49 / $113.20
| Professional | | $52.92 | $58.49 | $113.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.82 / $45.83 / $130.87
| Professional | | $37.82 | $45.83 | $130.87 |