- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.36 / $40.36 / $65.87
| Facility | | $40.36 | $40.36 | $65.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.36 / $55.64 / $65.87
| Professional | | $40.36 | $55.64 | $65.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.36 / $51.05 / $89.02
| Facility | | $40.36 | $51.05 | $89.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.36 / $55.64 / $65.87
| Professional | | $40.36 | $55.64 | $65.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.85 / $30.56 / $50.94
| Professional | | $28.85 | $30.56 | $50.94 |