- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.27 / $12.28 / $20.60
| Professional | | $12.27 | $12.28 | $20.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.31 / $14.31 / $14.31
| Facility | | $14.31 | $14.31 | $14.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.59 / $16.07 / $26.78
| Facility | | $11.59 | $16.07 | $26.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.28 / $12.28 / $26.78
| Professional | | $12.28 | $12.28 | $26.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.59 / $16.07 / $26.78
| Facility | | $11.59 | $16.07 | $26.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.28 / $12.28 / $26.78
| Professional | | $12.28 | $12.28 | $26.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.28 / $13.02 / $28.37
| Professional | | $12.28 | $13.02 | $28.37 |