- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.06 / $32.11 / $43.28
| Facility | | $13.06 | $32.11 | $43.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.06 / $13.06 / $13.06
| Professional | | $13.06 | $13.06 | $13.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.38 / $16.96 / $28.68
| Professional | | $11.38 | $16.96 | $28.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.32 / $12.32 / $13.06
| Facility | | $12.32 | $12.32 | $13.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.10 / $11.10 / $13.06
| Professional | | $11.10 | $11.10 | $13.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.88 / $13.06 / $21.17
| Professional | | $11.88 | $13.06 | $21.17 |