- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.65 / $128.54 / $156.56
| Facility | | $40.65 | $128.54 | $156.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.65 / $40.65 / $40.65
| Professional | | $40.65 | $40.65 | $40.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.65 / $41.20 / $41.20
| Professional | | $40.65 | $41.20 | $41.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.35 / $38.35 / $40.65
| Facility | | $38.35 | $38.35 | $40.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.65 / $40.65 / $51.78
| Professional | | $40.65 | $40.65 | $51.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.54 / $34.54 / $53.87
| Professional | | $34.54 | $34.54 | $53.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.65 / $40.65 / $65.88
| Professional | | $40.65 | $40.65 | $65.88 |