- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.10 / $75.72 / $78.09
| Facility | | $63.10 | $75.72 | $78.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.63 / $20.63 / $25.78
| Professional | | $20.63 | $20.63 | $25.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.62 / $20.62 / $20.62
| Facility | | $20.62 | $20.62 | $20.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.05 / $20.62 / $20.88
| Professional | | $13.05 | $20.62 | $20.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $90.00
| Facility | | $90.00 | $90.00 | $90.00 |