- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.55 / $55.12 / $142.63
| Facility | | $18.55 | $55.12 | $142.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.79 / $388.14 / $789.56
| Facility | | $287.79 | $388.14 | $789.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.71 / $173.71 / $208.13
| Professional | | $173.71 | $173.71 | $208.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.43 / $78.43 / $78.43
| Facility | | $78.43 | $78.43 | $78.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.71 / $363.71 / $363.71
| Professional | | $363.71 | $363.71 | $363.71 |