- 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 / $12.46
| Professional | | $10.30 | $10.30 | $12.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.50 / $10.50 / $13.13
| Professional | | $10.50 | $10.50 | $13.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.03 / $17.41 / $28.22
| Facility | | $11.03 | $17.41 | $28.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $11.33
| Professional | | $10.30 | $10.30 | $11.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.36 / $14.48 / $21.73
| Facility | | $12.36 | $14.48 | $21.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.12 / $13.10 / $20.51
| Professional | | $12.12 | $13.10 | $20.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.28 / $11.28 / $11.28
| Professional | | $11.28 | $11.28 | $11.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $11.33
| Professional | | $10.30 | $10.30 | $11.33 |
- 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 / $10.30
| Professional | | $10.30 | $10.30 | $10.30 |