- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.28 / $42.28 / $42.28
| Facility | | $42.28 | $42.28 | $42.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.28 / $42.28 / $42.48
| Professional | | $42.28 | $42.28 | $42.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.48 / $31.88 / $55.23
| Facility | | $27.48 | $31.88 | $55.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.28 / $42.28 / $60.71
| Professional | | $42.28 | $42.28 | $60.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.92 / $37.92 / $37.92
| Facility | | $37.92 | $37.92 | $37.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.73 / $25.37 / $42.28
| Professional | | $17.73 | $25.37 | $42.28 |