- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.70 / $26.61 / $26.61
| Professional | | $20.70 | $26.61 | $26.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.07 / $26.07 / $26.85
| Facility | | $26.07 | $26.07 | $26.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.07 / $22.16 / $23.06
| Professional | | $16.07 | $22.16 | $23.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.07 / $26.07 / $26.85
| Facility | | $26.07 | $26.07 | $26.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.07 / $22.16 / $23.06
| Professional | | $16.07 | $22.16 | $23.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.70 / $29.60 / $32.75
| Professional | | $16.70 | $29.60 | $32.75 |