- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.75 / $225.54 / $295.26
| Facility | | $212.75 | $225.54 | $295.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.60 / $34.06 / $60.61
| Professional | | $12.60 | $34.06 | $60.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.74 / $27.85 / $40.33
| Facility | | $20.74 | $27.85 | $40.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.62 / $14.94 / $31.04
| Facility | | $12.62 | $14.94 | $31.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.00 / $234.00 / $234.00
| Facility | | $5.00 | $234.00 | $234.00 |