- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.34 / $47.34 / $51.03
| Facility | | $47.34 | $47.34 | $51.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.67 / $47.34 / $84.86
| Professional | | $45.67 | $47.34 | $84.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,048.61 / $3,699.63 / $4,977.18
| Facility | | $3,048.61 | $3,699.63 | $4,977.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.34 / $47.34 / $47.34
| Facility | | $47.34 | $47.34 | $47.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.07 / $47.34 / $47.34
| Professional | | $14.07 | $47.34 | $47.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.23 / $46.41 / $50.33
| Professional | | $44.23 | $46.41 | $50.33 |