- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.41 / $45.41 / $55.28
| Facility | | $45.41 | $45.41 | $55.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.72 / $50.72 / $55.79
| Professional | | $50.72 | $50.72 | $55.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.41 / $45.41 / $50.72
| Professional | | $45.41 | $45.41 | $50.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.71 / $50.71 / $50.71
| Facility | | $50.71 | $50.71 | $50.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.71 / $50.71 / $50.71
| Professional | | $50.71 | $50.71 | $50.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.02 / $55.02 / $179.61
| Professional | | $55.02 | $55.02 | $179.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $127.38
| Professional | | $127.38 | $127.38 | $127.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.72 / $50.72 / $77.59
| Professional | | $50.72 | $50.72 | $77.59 |