- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.02 / $10.02 / $10.02
| Professional | | $10.02 | $10.02 | $10.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.52 / $13.52 / $13.52
| Facility | | $13.52 | $13.52 | $13.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.50 / $9.50 / $11.87
| Professional | | $9.50 | $9.50 | $11.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.52 / $13.52 / $13.52
| Facility | | $13.52 | $13.52 | $13.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $9.50 / $11.87
| Professional | | $5.25 | $9.50 | $11.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.84 / $4.84 / $11.31
| Professional | | $4.84 | $4.84 | $11.31 |