- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.62 / $26.62 / $26.62
| Professional | | $26.62 | $26.62 | $26.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.12 / $29.78 / $49.64
| Facility | | $25.12 | $29.78 | $49.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.62 / $26.62 / $26.62
| Professional | | $26.62 | $26.62 | $26.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.12 / $29.78 / $49.64
| Facility | | $25.12 | $29.78 | $49.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.62 / $26.62 / $26.62
| Professional | | $26.62 | $26.62 | $26.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.62 / $26.62 / $28.99
| Professional | | $26.62 | $26.62 | $28.99 |