- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.40 / $10.40 / $11.03
| Facility | | $10.40 | $10.40 | $11.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.40
| Professional | | $10.30 | $10.30 | $10.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.30 / $15.45 / $15.45
| Facility | | $10.30 | $15.45 | $15.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.72 / $10.30 / $85.00
| Facility | | $9.72 | $10.30 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $26.88
| Professional | | $10.30 | $10.30 | $26.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $12.60
| Professional | | $10.30 | $10.30 | $12.60 |