- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.75 / $141.11 / $216.46
| Facility | | $120.75 | $141.11 | $216.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.34 / $69.18 / $322.08
| Professional | | $55.34 | $69.18 | $322.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.26 / $31.26 / $43.08
| Facility | | $31.26 | $31.26 | $43.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.26 / $31.26 / $43.08
| Facility | | $31.26 | $31.26 | $43.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.26 / $31.26 / $43.08
| Facility | | $31.26 | $31.26 | $43.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.00 / $78.40 / $167.46
| Facility | | $60.00 | $78.40 | $167.46 |