- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.48 / $10.48 / $10.48
| Facility | | $10.48 | $10.48 | $10.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.48 / $10.48 / $10.48
| Professional | | $10.48 | $10.48 | $10.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.78 / $4.78 / $4.78
| Professional | | $4.78 | $4.78 | $4.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.48 / $10.48 / $10.48
| Facility | | $10.48 | $10.48 | $10.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.55 / $5.55 / $5.55
| Professional | | $5.55 | $5.55 | $5.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.35 / $10.27 / $16.64
| Professional | | $9.35 | $10.27 | $16.64 |