- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.30
| Facility | | $10.30 | $10.30 | $10.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $17.71
| Professional | | $10.30 | $10.30 | $17.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.43 / $135.22 / $181.92
| Facility | | $111.43 | $135.22 | $181.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.58
| Professional | | $10.30 | $10.30 | $10.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.30
| Facility | | $10.30 | $10.30 | $10.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $24.39
| Professional | | $10.30 | $10.30 | $24.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.30
| Professional | | $10.30 | $10.30 | $10.30 |