- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.27 / $21.27 / $21.27
| Facility | | $21.27 | $21.27 | $21.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.26 / $20.77 / $21.27
| Professional | | $17.26 | $20.77 | $21.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.27 / $21.27 / $27.52
| Facility | | $21.27 | $21.27 | $27.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.27 / $21.27 / $21.27
| Professional | | $21.27 | $21.27 | $21.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $21.48 / $24.54
| Professional | | $21.48 | $21.48 | $24.54 |