- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.40 / $25.20 / $46.80
| Facility | | $10.40 | $25.20 | $46.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.40 / $10.40
| Professional | | $10.30 | $10.40 | $10.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $20.60 / $27.30
| Facility | | $10.30 | $20.60 | $27.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.75 / $10.30 / $14.62
| Professional | | $8.75 | $10.30 | $14.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $13.91
| Facility | | $10.30 | $10.30 | $13.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $12.88
| Professional | | $10.30 | $10.30 | $12.88 |
- 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 / $29.45
| Professional | | $10.30 | $10.30 | $29.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $13.76
| Professional | | $10.30 | $10.30 | $13.76 |