- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $20.60
| Facility | | $10.30 | $10.30 | $20.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $24.52
| Professional | | $10.30 | $10.30 | $24.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $11.83 / $22.50
| Facility | | $10.30 | $11.83 | $22.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.96 / $36.07 / $43.92
| Facility | | $20.96 | $36.07 | $43.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.61 / $13.29 / $13.34
| Professional | | $10.61 | $13.29 | $13.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.07 / $32.92 / $41.31
| Facility | | $18.07 | $32.92 | $41.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.50 / $10.50 / $14.28
| Professional | | $10.50 | $10.50 | $14.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $10.87 / $26.66
| Facility | | $10.30 | $10.87 | $26.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $18.54
| Professional | | $10.30 | $10.30 | $18.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $18.67
| Professional | | $10.30 | $10.30 | $18.67 |