- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.05 / $11.05 / $11.05
| Facility | | $11.05 | $11.05 | $11.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.05 / $11.05 / $11.34
| Professional | | $11.05 | $11.05 | $11.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.50 / $13.64 / $16.88
| Professional | | $13.50 | $13.64 | $16.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.87 / $16.22 / $31.07
| Facility | | $10.87 | $16.22 | $31.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.86 / $11.10 / $19.43
| Professional | | $3.86 | $11.10 | $19.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.74 / $12.95 / $14.92
| Facility | | $12.74 | $12.95 | $14.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.90 / $14.42 / $24.41
| Professional | | $9.90 | $14.42 | $24.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.34 / $11.61 / $15.37
| Professional | | $11.34 | $11.61 | $15.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.86 / $5.80 / $19.43
| Professional | | $3.86 | $5.80 | $19.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.45 / $10.45 / $10.45
| Professional | | $10.45 | $10.45 | $10.45 |