- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.94 / $7.94 / $7.94
| Facility | | $7.94 | $7.94 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $7.94 / $10.96
| Professional | | $7.08 | $7.94 | $10.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $75.86 / $75.86
| Facility | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.51 / $12.02 / $54.95
| Professional | | $8.51 | $12.02 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.76 / $7.76 / $7.76
| Professional | | $7.76 | $7.76 | $7.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.76 / $7.94 / $10.00
| Facility | | $7.76 | $7.94 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $13.80 / $19.50
| Professional | | $9.77 | $13.80 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.33 / $15.14 / $23.44
| Professional | | $9.33 | $15.14 | $23.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $75.86 / $75.86
| Facility | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.71 / $12.30 / $54.95
| Professional | | $8.71 | $12.30 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.71 / $8.71 / $8.71
| Facility | | $8.71 | $8.71 | $8.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.71 / $12.59 / $23.44
| Professional | | $8.71 | $12.59 | $23.44 |