- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.02 / $11.02 / $13.35
| Professional | | $11.02 | $11.02 | $13.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.48 / $12.48 / $35.79
| Facility | | $12.48 | $12.48 | $35.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.91 / $10.91 / $12.48
| Professional | | $10.91 | $10.91 | $12.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.48 / $12.48 / $35.79
| Facility | | $12.48 | $12.48 | $35.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.91 / $11.97 / $15.62
| Professional | | $10.91 | $11.97 | $15.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.14 / $11.14 / $11.83
| Professional | | $11.14 | $11.14 | $11.83 |