- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.47 / $63.05 / $107.98
| Facility | | $52.47 | $63.05 | $107.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $62.97
| Professional | | $52.47 | $52.47 | $62.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.47 / $83.88 / $166.83
| Facility | | $52.47 | $83.88 | $166.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $54.22
| Professional | | $52.47 | $52.47 | $54.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.50 / $52.47 / $52.79
| Facility | | $49.50 | $52.47 | $52.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $56.93
| Professional | | $52.47 | $52.47 | $56.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $62.44
| Professional | | $52.47 | $52.47 | $62.44 |