- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.22 / $40.78 / $54.95
| Facility | | $16.22 | $40.78 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $16.22 / $16.22
| Professional | | $16.22 | $16.22 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.46 / $26.52 / $44.84
| Professional | | $14.46 | $26.52 | $44.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.30 / $15.30 / $16.22
| Facility | | $15.30 | $15.30 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.54 / $13.79 / $16.22
| Professional | | $10.54 | $13.79 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.76 / $16.22 / $23.40
| Professional | | $14.76 | $16.22 | $23.40 |