- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.65 / $2.65 / $2.65
| Facility | | $2.65 | $2.65 | $2.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.97 / $2.58 / $3.06
| Professional | | $1.97 | $2.58 | $3.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.56 / $3.32 / $6.83
| Professional | | $2.56 | $3.32 | $6.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.56 / $5.56 / $5.56
| Facility | | $5.56 | $5.56 | $5.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $2.75 / $6.06
| Professional | | $2.75 | $2.75 | $6.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.24 / $8.52 / $8.78
| Professional | | $3.24 | $8.52 | $8.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.44 / $2.16 / $4.88
| Professional | | $1.44 | $2.16 | $4.88 |