- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.22 / $21.22 / $21.22
| Facility | | $21.22 | $21.22 | $21.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.67 / $21.22 / $24.82
| Professional | | $13.67 | $21.22 | $24.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.73 / $22.93 / $27.06
| Professional | | $16.73 | $22.93 | $27.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.81 / $23.81 / $23.81
| Professional | | $23.81 | $23.81 | $23.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.01 / $21.11 / $30.27
| Professional | | $15.01 | $21.11 | $30.27 |