- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.73 / $7.16 / $11.46
| Facility | | $5.73 | $7.16 | $11.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.73 / $5.79 / $9.86
| Professional | | $5.73 | $5.79 | $9.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.41 / $9.74 / $11.46
| Facility | | $5.41 | $9.74 | $11.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.73 / $5.73 / $6.76
| Professional | | $5.73 | $5.73 | $6.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.76 / $12.82 / $16.67
| Professional | | $9.76 | $12.82 | $16.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.73 / $6.02 / $12.75
| Facility | | $5.73 | $6.02 | $12.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.73 / $6.76 / $7.46
| Professional | | $5.73 | $6.76 | $7.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.73 / $7.16 / $17.19
| Facility | | $5.73 | $7.16 | $17.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.73 / $7.14 / $12.32
| Facility | | $5.73 | $7.14 | $12.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.73 / $7.16 / $7.74
| Professional | | $5.73 | $7.16 | $7.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.74 / $9.18 / $20.96
| Facility | | $5.74 | $9.18 | $20.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.73 / $5.73 / $6.30
| Professional | | $5.73 | $5.73 | $6.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.73 / $5.73 / $6.65
| Professional | | $5.73 | $5.73 | $6.65 |