- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.38 / $87.77 / $222.57
| Facility | | $50.38 | $87.77 | $222.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.38 / $50.38 / $50.38
| Professional | | $50.38 | $50.38 | $50.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.43 / $73.90 / $105.80
| Facility | | $45.43 | $73.90 | $105.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.38 / $50.38 / $50.38
| Facility | | $50.38 | $50.38 | $50.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |