- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.25 / $2.25 / $2.70
| Facility | | $2.25 | $2.25 | $2.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.04 / $2.22 / $2.25
| Professional | | $1.04 | $2.22 | $2.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.27 / $3.78 / $3.78
| Professional | | $2.27 | $3.78 | $3.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.31 / $3.31 / $3.31
| Facility | | $3.31 | $3.31 | $3.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.70 / $3.31 / $3.31
| Professional | | $2.70 | $3.31 | $3.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.27 / $2.27 / $2.40
| Facility | | $2.27 | $2.27 | $2.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.93 / $2.27 / $2.67
| Professional | | $1.93 | $2.27 | $2.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.04 / $2.36 / $80.00
| Facility | | $1.04 | $2.36 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.07 / $1.80 / $3.74
| Professional | | $1.07 | $1.80 | $3.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.07 / $1.60 / $2.29
| Professional | | $1.07 | $1.60 | $2.29 |