- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.68 / $10.68 / $43.18
| Facility | | $10.68 | $10.68 | $43.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.43 / $10.68 / $10.68
| Professional | | $10.43 | $10.68 | $10.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.06 / $11.06 / $13.95
| Professional | | $11.06 | $11.06 | $13.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.87 / $7.87 / $7.87
| Professional | | $7.87 | $7.87 | $7.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.10 / $10.68 / $15.08
| Facility | | $0.10 | $10.68 | $15.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.31 / $10.31 / $12.88
| Professional | | $10.31 | $10.31 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.57 / $12.57 / $12.57
| Professional | | $12.57 | $12.57 | $12.57 |