- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.74 / $20.74 / $20.74
| Facility | | $20.74 | $20.74 | $20.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.28 / $20.74 / $22.56
| Professional | | $18.28 | $20.74 | $22.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.41 / $25.17 / $26.49
| Professional | | $24.41 | $25.17 | $26.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.74 / $20.74 / $20.74
| Facility | | $20.74 | $20.74 | $20.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.30 / $20.74 / $23.05
| Professional | | $19.30 | $20.74 | $23.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.79 / $59.70 / $100.00
| Professional | | $39.79 | $59.70 | $100.00 |