- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.77 / $47.77 / $47.77
| Facility | | $47.77 | $47.77 | $47.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.53 / $47.77 / $54.67
| Professional | | $18.53 | $47.77 | $54.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.74 / $48.74 / $48.74
| Professional | | $48.74 | $48.74 | $48.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.47 / $39.47 / $48.77
| Facility | | $39.47 | $39.47 | $48.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.56 / $39.47 / $64.19
| Professional | | $33.56 | $39.47 | $64.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.57 / $30.32 / $44.51
| Professional | | $18.57 | $30.32 | $44.51 |