- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.10 / $74.13 / $117.49
| Facility | | $63.10 | $74.13 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.84 / $36.31 / $43.65
| Professional | | $28.84 | $36.31 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.22 / $16.22 / $22.91
| Facility | | $16.22 | $16.22 | $22.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.22 / $16.22 / $22.91
| Facility | | $16.22 | $16.22 | $22.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $100.00
| Facility | | $60.26 | $60.26 | $100.00 |