- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.35 / $21.35 / $21.35
| Facility | | $21.35 | $21.35 | $21.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.59 / $22.86 / $33.70
| Professional | | $20.59 | $22.86 | $33.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.13 / $33.83 / $37.33
| Professional | | $33.13 | $33.83 | $37.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.35 / $21.35 / $21.35
| Facility | | $21.35 | $21.35 | $21.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.02 / $22.41 / $34.58
| Professional | | $21.02 | $22.41 | $34.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.60 / $78.90 / $100.00
| Professional | | $52.60 | $78.90 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.00 / $62.00 / $70.00
| Professional | | $56.00 | $62.00 | $70.00 |