- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $102.33 / $165.96
| Facility | | $89.13 | $102.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $50.12 / $60.26
| Professional | | $40.74 | $50.12 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.91 / $22.91 / $32.36
| Facility | | $22.91 | $22.91 | $32.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.91 / $22.91 / $32.36
| Facility | | $22.91 | $22.91 | $32.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $123.03
| Facility | | $60.26 | $60.26 | $123.03 |