- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.52 / $10.52 / $10.52
| Facility | | $10.52 | $10.52 | $10.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.21 / $10.52 / $11.12
| Professional | | $9.21 | $10.52 | $11.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.72 / $11.14 / $11.73
| Professional | | $10.72 | $11.14 | $11.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.52 / $10.52 / $10.52
| Facility | | $10.52 | $10.52 | $10.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.21 / $10.52 / $11.55
| Professional | | $9.21 | $10.52 | $11.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.60 / $26.40 / $100.00
| Professional | | $17.60 | $26.40 | $100.00 |