- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.13 / $14.13 / $15.14
| Facility | | $14.13 | $14.13 | $15.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.03 / $15.14 / $26.92
| Facility | | $6.03 | $15.14 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |