- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $11.85
| Facility | | $10.30 | $10.30 | $11.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $11.33 / $12.87
| Professional | | $10.30 | $11.33 | $12.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.72 / $10.30 / $10.30
| Facility | | $9.72 | $10.30 | $10.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.30
| Professional | | $10.30 | $10.30 | $10.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.33 / $13.64 / $21.38
| Facility | | $11.33 | $13.64 | $21.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $11.93 / $12.88
| Professional | | $10.30 | $11.93 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.30
| Professional | | $10.30 | $10.30 | $10.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.24 / $16.70 / $28.38
| Facility | | $12.24 | $16.70 | $28.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.36 / $12.36 / $12.88
| Professional | | $12.36 | $12.36 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $16.48
| Professional | | $10.30 | $10.30 | $16.48 |