- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Professional | | $20.43 | $20.43 | $20.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.32 / $24.27 / $63.32
| Facility | | $19.32 | $24.27 | $63.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.42 / $20.42 / $20.42
| Professional | | $20.42 | $20.42 | $20.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Facility | | $20.43 | $20.43 | $20.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Professional | | $20.43 | $20.43 | $20.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Professional | | $20.43 | $20.43 | $20.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Professional | | $20.43 | $20.43 | $20.43 |