- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.02 / $25.02 / $25.02
| Facility | | $25.02 | $25.02 | $25.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.27 / $25.02 / $25.02
| Professional | | $21.27 | $25.02 | $25.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.27 / $21.27 / $21.27
| Professional | | $21.27 | $21.27 | $21.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.02 / $38.06 / $45.04
| Facility | | $25.02 | $38.06 | $45.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $21.48 / $23.63
| Professional | | $21.48 | $21.48 | $23.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.54 / $26.54 / $26.54
| Professional | | $26.54 | $26.54 | $26.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $21.48 / $23.63
| Professional | | $21.48 | $21.48 | $23.63 |