- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.36 / $22.36 / $22.36
| Facility | | $22.36 | $22.36 | $22.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.36 / $22.36 / $28.62
| Professional | | $22.36 | $22.36 | $28.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $21.05
| Professional | | $21.05 | $21.05 | $21.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $26.81
| Professional | | $21.05 | $21.05 | $26.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.62 / $25.10 / $32.43
| Professional | | $21.62 | $25.10 | $32.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $22.31
| Professional | | $21.05 | $21.05 | $22.31 |