- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.07 / $13.07 / $13.07
| Facility | | $13.07 | $13.07 | $13.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.07 / $13.07 / $13.07
| Professional | | $13.07 | $13.07 | $13.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.86 / $15.26 / $15.41
| Professional | | $13.86 | $15.26 | $15.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.10 / $17.36 / $17.36
| Facility | | $8.10 | $17.36 | $17.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.49 / $17.36 / $26.76
| Professional | | $9.49 | $17.36 | $26.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.94 / $15.80 / $80.00
| Facility | | $11.94 | $15.80 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.55 / $7.87 / $13.12
| Professional | | $5.55 | $7.87 | $13.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.30 / $17.36 / $21.87
| Facility | | $17.30 | $17.36 | $21.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.21 / $20.28 / $34.36
| Professional | | $14.21 | $20.28 | $34.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.55 / $7.87 / $10.32
| Professional | | $5.55 | $7.87 | $10.32 |