- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $26.27 / $40.60
| Professional | | $23.65 | $26.27 | $40.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.77 / $26.77 / $26.77
| Facility | | $26.77 | $26.77 | $26.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.31 / $26.19 / $43.65
| Facility | | $22.31 | $26.19 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $23.65
| Professional | | $23.65 | $23.65 | $23.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.31 / $26.19 / $43.65
| Facility | | $22.31 | $26.19 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $23.65
| Professional | | $23.65 | $23.65 | $23.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.47 / $23.65 / $25.07
| Professional | | $22.47 | $23.65 | $25.07 |