- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.51 / $85.51 / $85.51
| Facility | | $85.51 | $85.51 | $85.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $22.36
| Professional | | $21.05 | $21.05 | $22.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $21.05
| Facility | | $21.05 | $21.05 | $21.05 |
- 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 / $26.31
| Professional | | $21.05 | $21.05 | $26.31 |