- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.48 / $27.48 / $27.48
| Facility | | $27.48 | $27.48 | $27.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.46 / $20.63 / $27.48
| Professional | | $11.46 | $20.63 | $27.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.66 / $56.66 / $56.66
| Professional | | $56.66 | $56.66 | $56.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.62 / $23.13 / $34.44
| Facility | | $10.62 | $23.13 | $34.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.20 / $120.20 / $120.20
| Professional | | $120.20 | $120.20 | $120.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $56.00 / $61.00
| Professional | | $50.00 | $56.00 | $61.00 |