- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.73 / $108.87 / $116.40
| Facility | | $90.73 | $108.87 | $116.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.08 / $47.08 / $58.85
| Professional | | $47.08 | $47.08 | $58.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.63 / $26.73 / $62.91
| Facility | | $20.63 | $26.73 | $62.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.46 / $13.46 / $13.46
| Professional | | $13.46 | $13.46 | $13.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.25 / $143.88 / $143.88
| Facility | | $71.25 | $143.88 | $143.88 |