- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.56 / $14.56 / $17.98
| Professional | | $14.56 | $14.56 | $17.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.19 / $10.78 / $20.48
| Professional | | $7.19 | $10.78 | $20.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.57 / $18.32 / $31.82
| Professional | | $12.57 | $18.32 | $31.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.98 / $21.58 / $39.03
| Professional | | $17.98 | $21.58 | $39.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.56 / $17.98 / $17.98
| Professional | | $14.56 | $17.98 | $17.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.98 / $29.74 / $43.71
| Professional | | $17.98 | $29.74 | $43.71 |