- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.58 / $10.58 / $10.58
| Facility | | $10.58 | $10.58 | $10.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $10.58 / $10.58
| Professional | | $10.58 | $10.58 | $10.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.19 / $220.74 / $310.05
| Professional | | $87.19 | $220.74 | $310.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.53 / $277.67 / $317.33
| Facility | | $255.53 | $277.67 | $317.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.44 / $204.44 / $255.54
| Professional | | $204.44 | $204.44 | $255.54 |