- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.08 / $73.70 / $113.08
| Facility | | $63.08 | $73.70 | $113.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.91 / $36.14 / $168.25
| Professional | | $28.91 | $36.14 | $168.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.32 / $16.32 / $22.50
| Facility | | $16.32 | $16.32 | $22.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.32 / $16.32 / $22.50
| Facility | | $16.32 | $16.32 | $22.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.32 / $16.32 / $22.50
| Facility | | $16.32 | $16.32 | $22.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $100.00
| Facility | | $60.00 | $60.00 | $100.00 |