- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.98 / $28.24 / $84.11
| Facility | | $13.98 | $28.24 | $84.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.98 / $13.98 / $13.98
| Professional | | $13.98 | $13.98 | $13.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.52 / $15.26 / $17.55
| Facility | | $13.52 | $15.26 | $17.55 |
- 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
- $11.46 / $12.06 / $12.06
| Professional | | $11.46 | $12.06 | $12.06 |