- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.40 / $10.40 / $46.80
| Facility | | $10.40 | $10.40 | $46.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.40 / $10.40 / $10.40
| Professional | | $10.40 | $10.40 | $10.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.70 / $12.70 / $24.51
| Facility | | $12.70 | $12.70 | $24.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.79 / $12.70 / $17.14
| Professional | | $10.79 | $12.70 | $17.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.05 / $11.05 / $11.05
| Facility | | $11.05 | $11.05 | $11.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.05 / $11.05 / $30.39
| Professional | | $11.05 | $11.05 | $30.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.00 / $13.00 / $16.12
| Professional | | $13.00 | $13.00 | $16.12 |