- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.90 / $36.65 / $222.89
| Facility | | $32.90 | $36.65 | $222.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.65 / $36.65 / $37.60
| Professional | | $36.65 | $36.65 | $37.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.00 / $49.35 / $64.86
| Professional | | $47.00 | $49.35 | $64.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.42 / $115.78 / $267.98
| Facility | | $85.42 | $115.78 | $267.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.65 / $47.00 / $56.40
| Facility | | $36.65 | $47.00 | $56.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.73 / $28.20 / $42.80
| Professional | | $19.73 | $28.20 | $42.80 |