- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.03 / $17.03 / $17.03
| Facility | | $17.03 | $17.03 | $17.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.43 / $17.03 / $28.32
| Professional | | $16.43 | $17.03 | $28.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.98 / $16.98 / $16.98
| Facility | | $16.98 | $16.98 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $16.98 / $31.67
| Professional | | $16.98 | $16.98 | $31.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.04 / $20.04 / $20.04
| Professional | | $20.04 | $20.04 | $20.04 |