- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $10.68
| Facility | | $10.68 | $10.68 | $10.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $12.28
| Professional | | $10.68 | $10.68 | $12.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.25 / $17.75 / $48.68
| Facility | | $14.25 | $17.75 | $48.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.44 / $22.11 / $46.60
| Facility | | $13.44 | $22.11 | $46.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.49 / $11.53 / $15.79
| Professional | | $10.49 | $11.53 | $15.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.92 / $22.25 / $50.71
| Facility | | $12.92 | $22.25 | $50.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.39 / $10.39 / $14.13
| Professional | | $10.39 | $10.39 | $14.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.73 / $9.73 / $55.23
| Facility | | $9.73 | $9.73 | $55.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.73 / $10.83 / $46.40
| Professional | | $9.73 | $10.83 | $46.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $11.32 / $20.43
| Professional | | $10.68 | $11.32 | $20.43 |