- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.60 / $2.60 / $2.60
| Facility | | $2.60 | $2.60 | $2.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.60 / $2.60 / $3.47
| Professional | | $2.60 | $2.60 | $3.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $3.04 / $3.06
| Professional | | $2.75 | $3.04 | $3.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.89 / $3.45 / $3.45
| Facility | | $1.89 | $3.45 | $3.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.89 / $3.45 / $5.32
| Professional | | $1.89 | $3.45 | $5.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.54 / $3.44 / $90.00
| Facility | | $2.54 | $3.44 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.20 / $1.58 / $3.37
| Professional | | $1.20 | $1.58 | $3.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.44 / $3.45 / $4.36
| Facility | | $3.44 | $3.45 | $4.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.29 / $4.13 / $6.84
| Professional | | $3.29 | $4.13 | $6.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.20 / $1.57 / $3.31
| Professional | | $1.20 | $1.57 | $3.31 |