- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $54.95 / $57.54
| Facility | | $47.86 | $54.95 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.48 / $35.48 / $35.48
| Professional | | $35.48 | $35.48 | $35.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $45.71 / $74.13
| Facility | | $30.20 | $45.71 | $74.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $181.97
| Facility | | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $190.55
| Professional | | $190.55 | $190.55 | $190.55 |