- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.56 / $80.87 / $80.87
| Facility | | $65.56 | $80.87 | $80.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.98 / $65.56 / $80.87
| Professional | | $27.98 | $65.56 | $80.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.50 / $40.22 / $80.94
| Professional | | $27.50 | $40.22 | $80.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.68 / $80.87 / $132.47
| Facility | | $35.68 | $80.87 | $132.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.72 / $382.72 / $382.72
| Professional | | $382.72 | $382.72 | $382.72 |