- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.38 / $12.49 / $12.49
| Facility | | $12.38 | $12.49 | $12.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.49 / $12.49 / $13.12
| Professional | | $12.49 | $12.49 | $13.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.78 / $12.49 / $12.49
| Facility | | $11.78 | $12.49 | $12.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.49 / $12.49 / $12.49
| Professional | | $12.49 | $12.49 | $12.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.49 / $12.49 / $12.49
| Facility | | $12.49 | $12.49 | $12.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.25 / $12.49 / $12.49
| Professional | | $6.25 | $12.49 | $12.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.67 / $22.43 / $67.04
| Professional | | $18.67 | $22.43 | $67.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.49 / $12.49 / $12.99
| Professional | | $12.49 | $12.49 | $12.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.38 / $12.38 / $12.49
| Professional | | $12.38 | $12.38 | $12.49 |