- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.83 / $20.83 / $20.83
| Facility | | $20.83 | $20.83 | $20.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.83 / $20.83 / $29.28
| Professional | | $20.83 | $20.83 | $29.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.87 / $12.32 / $15.95
| Professional | | $10.87 | $12.32 | $15.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $89.00 / $171.00
| Facility | | $80.00 | $89.00 | $171.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |