- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.67 / $10.68 / $16.72
| Professional | | $10.67 | $10.68 | $16.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.09 / $12.09 / $12.09
| Facility | | $12.09 | $12.09 | $12.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.07 / $11.55 / $19.25
| Facility | | $10.07 | $11.55 | $19.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $19.25
| Professional | | $10.68 | $10.68 | $19.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.07 / $11.55 / $19.25
| Facility | | $10.07 | $11.55 | $19.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $19.25
| Professional | | $10.68 | $10.68 | $19.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.68 / $11.32 / $32.04
| Professional | | $10.68 | $11.32 | $32.04 |