- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Facility | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $46.77 / $57.54
| Professional | | $46.77 | $46.77 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $263.03 / $354.81
| Facility | | $218.78 | $263.03 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $47.86 / $47.86
| Professional | | $45.71 | $47.86 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Facility | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Professional | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $51.29
| Facility | | $47.86 | $47.86 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $47.86 / $51.29
| Professional | | $40.74 | $47.86 | $51.29 |