- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.71 / $13.37 / $27.49
| Facility | | $10.71 | $13.37 | $27.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $11.13 / $18.34
| Professional | | $10.30 | $11.13 | $18.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.77 / $28.43 / $34.11
| Facility | | $19.77 | $28.43 | $34.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $17.35
| Professional | | $10.30 | $10.30 | $17.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.30
| Facility | | $10.30 | $10.30 | $10.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $12.60
| Professional | | $10.30 | $10.30 | $12.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.13 / $12.26 / $13.86
| Facility | | $11.13 | $12.26 | $13.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.65 / $9.65 / $9.65
| Professional | | $9.65 | $9.65 | $9.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $13.39
| Professional | | $10.30 | $10.30 | $13.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $100.00 / $100.00
| Facility | | $75.00 | $100.00 | $100.00 |