- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.96 / $27.25 / $33.52
| Professional | | $25.96 | $27.25 | $33.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.52 / $17.39 / $17.39
| Facility | | $16.52 | $17.39 | $17.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.22 / $17.22 / $17.22
| Professional | | $17.22 | $17.22 | $17.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.96 / $27.25 / $33.52
| Facility | | $25.96 | $27.25 | $33.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.47 / $28.38 / $28.38
| Professional | | $27.47 | $28.38 | $28.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.02 / $28.02 / $28.38
| Professional | | $28.02 | $28.02 | $28.38 |