- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.66 / $60.02 / $165.15
| Facility | | $12.66 | $60.02 | $165.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.06 / $12.66 / $14.47
| Professional | | $12.06 | $12.66 | $14.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.21 / $12.05 / $12.05
| Facility | | $10.21 | $12.05 | $12.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.05 / $12.05 / $12.05
| Professional | | $12.05 | $12.05 | $12.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.58 / $12.06 / $15.68
| Professional | | $11.58 | $12.06 | $15.68 |