- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.88 / $11.88 / $35.43
| Professional | | $11.88 | $11.88 | $35.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.21 / $13.60 / $22.66
| Facility | | $11.21 | $13.60 | $22.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.88 / $11.88 / $22.66
| Professional | | $11.88 | $11.88 | $22.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.21 / $13.60 / $22.66
| Facility | | $11.21 | $13.60 | $22.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.88 / $11.88 / $22.66
| Professional | | $11.88 | $11.88 | $22.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.47 / $11.88 / $35.64
| Professional | | $11.47 | $11.88 | $35.64 |