- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.75 / $1.75 / $1.75
| Facility | | $1.75 | $1.75 | $1.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.75 / $1.75 / $1.82
| Professional | | $1.75 | $1.75 | $1.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.47 / $3.14 / $6.17
| Facility | | $1.47 | $3.14 | $6.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.99 / $1.08 / $1.35
| Professional | | $0.99 | $1.08 | $1.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.03 / $0.20 / $0.42
| Professional | | $0.03 | $0.20 | $0.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.75 / $1.75 / $1.75
| Facility | | $1.75 | $1.75 | $1.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.75 / $1.75 / $1.82
| Professional | | $1.75 | $1.75 | $1.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |