- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.18 / $81.28 / $128.82
| Facility | | $69.18 | $81.28 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $39.81 / $47.86
| Professional | | $31.62 | $39.81 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.20 / $18.20 / $25.12
| Facility | | $18.20 | $18.20 | $25.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.20 / $18.20 / $25.12
| Facility | | $18.20 | $18.20 | $25.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $102.33
| Facility | | $60.26 | $60.26 | $102.33 |