- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.78 / $13.78 / $40.92
| Professional | | $13.78 | $13.78 | $40.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.64 / $13.64 / $50.72
| Facility | | $13.64 | $13.64 | $50.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.06 / $13.06 / $13.64
| Professional | | $13.06 | $13.06 | $13.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.64 / $13.64 / $50.72
| Facility | | $13.64 | $13.64 | $50.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.06 / $14.17 / $18.48
| Professional | | $13.06 | $14.17 | $18.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.06 / $13.06 / $13.06
| Professional | | $13.06 | $13.06 | $13.06 |