- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.10 / $11.10 / $11.10
| Facility | | $11.10 | $11.10 | $11.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.11 / $10.11 / $11.10
| Professional | | $10.11 | $10.11 | $11.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.52 / $17.50 / $21.07
| Professional | | $14.52 | $17.50 | $21.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.78 / $17.09 / $20.22
| Facility | | $11.78 | $17.09 | $20.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $17.61 / $153.85
| Professional | | $11.36 | $17.61 | $153.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.95 / $20.56 / $35.11
| Facility | | $11.95 | $20.56 | $35.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.94 / $19.48 / $24.59
| Professional | | $17.94 | $19.48 | $24.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.42 / $17.14 / $18.94
| Professional | | $11.42 | $17.14 | $18.94 |