- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.87 / $4.87 / $4.87
| Facility | | $4.87 | $4.87 | $4.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.36 / $4.87 / $6.16
| Professional | | $3.36 | $4.87 | $6.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $5.01 / $5.01
| Professional | | $5.01 | $5.01 | $5.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.85 / $6.40 / $14.24
| Professional | | $3.85 | $6.40 | $14.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.87 / $6.55 / $12.32
| Facility | | $4.87 | $6.55 | $12.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.55 / $6.55 / $6.55
| Professional | | $6.55 | $6.55 | $6.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.62 / $4.62 / $5.71
| Facility | | $4.62 | $4.62 | $5.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.93 / $3.93 / $8.96
| Professional | | $3.93 | $3.93 | $8.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.85 / $7.70 / $13.86
| Professional | | $5.85 | $7.70 | $13.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.56 / $3.68 / $6.33
| Professional | | $2.56 | $3.68 | $6.33 |