- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.41 / $76.54 / $77.51
| Facility | | $67.41 | $76.54 | $77.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.41 / $68.54 / $77.51
| Professional | | $67.41 | $68.54 | $77.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.80 / $12.80 / $14.08
| Facility | | $12.80 | $12.80 | $14.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.00 / $14.00 / $15.40
| Facility | | $14.00 | $14.00 | $15.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.00 / $14.00 / $14.00
| Professional | | $14.00 | $14.00 | $14.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.36 / $16.00 / $20.48
| Professional | | $15.36 | $16.00 | $20.48 |