- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.38 / $48.38 / $94.58
| Facility | | $48.38 | $48.38 | $94.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.53 / $47.53 / $58.63
| Professional | | $47.53 | $47.53 | $58.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.52 / $47.52 / $48.38
| Professional | | $47.52 | $47.52 | $48.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.52 / $47.52 / $60.53
| Professional | | $47.52 | $47.52 | $60.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.53 / $47.53 / $103.59
| Professional | | $47.53 | $47.53 | $103.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.53 / $47.53 / $53.99
| Professional | | $47.53 | $47.53 | $53.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.30 / $49.30 / $49.30
| Professional | | $49.30 | $49.30 | $49.30 |