- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.57 / $2.57 / $2.57
| Facility | | $2.57 | $2.57 | $2.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.83 / $2.57 / $2.57
| Professional | | $1.83 | $2.57 | $2.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.73 / $3.00 / $3.02
| Professional | | $2.73 | $3.00 | $3.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.85 / $3.41 / $3.41
| Facility | | $1.85 | $3.41 | $3.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.32 / $3.75 / $5.24
| Professional | | $3.32 | $3.75 | $5.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.34 / $3.10 / $80.00
| Facility | | $2.34 | $3.10 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.03 / $1.54 / $2.57
| Professional | | $1.03 | $1.54 | $2.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.40 / $3.41 / $4.28
| Facility | | $3.40 | $3.41 | $4.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.77 / $3.98 / $6.73
| Professional | | $2.77 | $3.98 | $6.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.12 / $1.54 / $2.41
| Professional | | $1.12 | $1.54 | $2.41 |