- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.10 / $8.10 / $8.10
| Facility | | $8.10 | $8.10 | $8.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.87 / $8.10 / $8.10
| Professional | | $5.87 | $8.10 | $8.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.09 / $32.06 / $58.38
| Facility | | $16.09 | $32.06 | $58.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.10 / $10.63 / $14.35
| Professional | | $10.10 | $10.63 | $14.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.91 / $6.91 / $6.91
| Facility | | $6.91 | $6.91 | $6.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $10.00 / $10.00
| Professional | | $10.00 | $10.00 | $10.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.95 / $7.51 / $7.51
| Facility | | $4.95 | $7.51 | $7.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.95 / $7.51 / $14.25
| Professional | | $4.95 | $7.51 | $14.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.68 / $7.68 / $8.10
| Facility | | $7.68 | $7.68 | $8.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.09 / $8.10 / $11.96
| Professional | | $7.09 | $8.10 | $11.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.07 / $9.03 / $30.00
| Professional | | $5.07 | $9.03 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.15 / $5.08 / $7.60
| Professional | | $4.15 | $5.08 | $7.60 |