- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.43 / $10.43 / $13.64
| Facility | | $10.43 | $10.43 | $13.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.43 / $10.43 / $13.64
| Professional | | $10.43 | $10.43 | $13.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.10 / $13.50 / $15.88
| Professional | | $13.10 | $13.50 | $15.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.50 / $16.67 / $20.63
| Professional | | $16.50 | $16.67 | $20.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.43 / $12.41 / $31.29
| Facility | | $10.43 | $12.41 | $31.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.15 / $11.92 / $22.82
| Professional | | $7.15 | $11.92 | $22.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.60 / $11.92 / $22.82
| Professional | | $5.60 | $11.92 | $22.82 |