- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $17.70
| Professional | | $10.30 | $10.30 | $17.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.66 / $11.66 / $11.66
| Facility | | $11.66 | $11.66 | $11.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.72 / $11.66 / $19.43
| Facility | | $9.72 | $11.66 | $19.43 |
- 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
- $9.72 / $11.66 / $19.43
| Facility | | $9.72 | $11.66 | $19.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.30
| Professional | | $10.30 | $10.30 | $10.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.71
| Professional | | $10.30 | $10.30 | $10.71 |